EL-SHARNOBY PEDIATRICS MADE EASY

Collection of pediatrics lectures

OF DR. SAMEH EL-SHARNOBY
CONSULTANT OF PEDIATRICS EL-MINSHAWY HOSPITAL
EDITED BY: DR/ SHALABY

[1]

Index
Chapter Chapter A Antipyretics Chapter B Antibiotics Chaper C Respiratory system -Drugs of respiratory system: Decongestants: Local Systemic Cough preparations: Antitussives Mucolytic&expectorants Bronchodilators -Diseases of respiratory system Common cold Allergic rhinitis Sinusitis Tonsillitis Otitis media Croup Bronchitis Wheezy bronchitis Bronchial asthma Chapter D GIT -Drugs of GIT Antiemetics Spasmolytics&Antiflutlent Antihelminthic drugs Antiprotozoal drugs
page

Chapter -Diseases of GIT Teething&its problems

page

Gigivostomatitis
Gastroesophogeal reflux disease

Gastroentreritis Constipation Abdominal pain Acute Recurrent Chapter E Cardiovascular system -Congental heart diseases -Rheumatic fever -Heart failure Chapter F Heamatology How to read CBC Anemia: Iron deficiency anemia Hemolytic anemia G6pd deficiency Sickle cell anemia Thalassemia Bleeding disorders Hemophilia

[2]

Chapepter E CNS Convulsion Febrile convulsion CNS infection Encephalitis Meningitis Gullian barre' syndrome

Chapter G

Dermatology
Pteriasis alba Infantile eczema URTICARIA

Short notes on epilepsy

Napkin dermatitis Causes of fever with rash Chapter H Ricket

Headache

Chapter F

Urine analysis

Urinary tract infection

Acute post streptococcal Glomerulonephritis Nephritic syndrome Nocturnal enuresis

[3]

Antipyretics

[4]

Antipyretics
paracetamol 10-15mg/kg/dose Drops.
Every 6-8 hours

Cetal ,pyral ,tempra 1-2 drop/kg/dose every 6-8 H Syrup. -Most preparations contain 100-160mg/5ml e.g tempra, abimol, paramol, pyremol -dose= 5ml/10kg/dose every 6-8 hours exception cetal syrup 250mg/5ml(wt/5 per dose)
temporal syrup250mg/5ml(wt/5per dose) fevano syrup200mg/5ml (wt/4 per dose)

-Most safe analgesic Antipyretic -can be used from 1st Day of life -safe in asthmatics -its not antiinflammatory

supp -most preparations contain 100-160mg/supp -e.g cetal, paramol, paralex supp -dose=1 supp/10mg/dose every 6-8 H exception Abimol, supp 300mg/supp pyral supp 250mg/supp Grippo supp 200mg/supp

Ibuprofen

10-15mg/kg/dose Every 6-8 hours

Drops -safe from 6 Flabu 40mg/ml months ongoing Syrup Brufen, ultrafen 100mg/5ml Dose=wt/2 every 6-8 hours Supp Marcofen supp 100 &300 mg/supp Ultrafen supp 200 &5oo mg/supp Tab Brufen , ultrafen 200, 400, 600 mg/tab

[5]

Declophenac

,5-1 mg/kg/dose Drops With maximum Dolphin k, cataflam 1-2drop/kg/dose 3,5 mg/kg/day Syrup Catafly Supp Dolphin,Babyrelief,voltaren,Epifenac (Na) 12,5 &25 mg/supp Adwiflam(K) 25 mg/supp
(<

-Safe after 1 year only -not allowed in asthmatic

(drug induced bronchopasm)

3years use 12.5mg supp / 8 hour)

Injection Declophen amp 75mg/3ml Dose=1 cm / 20-25kg -Tab Roanal 500mg/tab Alexoprine 300mg/tab -Injection. Aspegic 500mg/vial Dose= 1cm / 10kg per dose IV -Supp Vegaskine supp Doloran supp

Acetylsalicylic acid

10-15mg/kg/dose

Absolutely Contraindicated with Viral infections for fear Of Reys $(see below)

Mefenamic Acid Nimsulide metimazol

Ponstan susp 50mg/5ml Ponstan, mefentan cap 250 mg/U Withdrawn from market are obsulted in pedaitrics

Safe in G6PD

[6]

N.B1 Antipyretics do not act in presence of high fever so lowering of body tempreture

By tiped spongs ( )must be done first

N.B 2

REYES $

syndrome is characterized by acute encephalopathy and fatty degeneration of the live -SYMPTOMS AT TIME OF ADMISSION: 1.Usually quiet, lethargic and sleepy, vomiting, laboratory evidence of liver dysfunction 2.Deep lethargy, confusion, delirium, combative, hyperventilation, hyper-reflexic 3.Obtunded, light coma seizures, decorticate rigidity, intact pupillary light reaction 4.Seizures, deepening coma, decerebrate rigidity, loss of oculocephalic reflexes, fixed pupils 5.Coma, loss of deep tendon reflexes, respiratory arrest, fixed dilated pupils, flaccidity/decerebrate (intermittent); isoelectric electroencephalogram -Diagnosis: -There is explosive release from liver and muscle of such enzymes as aminotransferases, creatine kinase, and lactic dehydrogenasea -threefold or higher elevation in serum ammonia level are more likely to progress

to com -treatment: -mainly supportive

N.B3

Choice of antipyretics by age group

< 6 months..paracetamol 6months-1yearparacetamol &ibuprofen >1 yearparacetamol , ibuprofen &declophenac

N.B 4

The best manner to use antipyretics is : To use two drugs of two different groups(paracetamol+ either ibuprofen declophenac) alternatively How ? paracetamolafter 4 hoursibuprofenafter 4 Hparacetamol after 4 H ibuprofen and so on
-

[7]

Antibiotics

[8]

Pencillins
A-natural pencillin 1-benzyl pencillin 2-phenoxy methyl pencillin

Antibiotics
Pencillin G vial 1.000.000u Aqua-pen vial 1.000.000 u
-Mainly Gram +ve But not antistaph -no need for sensitivity Test

50.000-100.000 unit/kg/ day Iv or im Every 6 hours (in neonates every 12 h) Unstable once dissolved Must be administrated 50.000-100.000 unit/kg/ day orrally every 6-8hours

3-benzathine pencillin

< 27 kg 1/2 vial > 27 kg1 vial Or < 3 years1/4 vial 3-6 year1/2 vial >6 years1 vial I M every 2 weeks

Ospen susp 400.000 unit/5ml tab 1.000.000 unit/tab Cliacil susp 300.000 unit/5ml tab 1.000.000 unit/tab Depopen vial--1.200.000unit Lastipen vial--1.200.000unit

For prophylaxis in RF Its given every 12 hour Mainly used in prophylaxis of RF Every 2 weeks -sensitivity test must be Done before each injection -can be dissolved in Lidocaine -Mainly used in Strept pharyngitis -sensitivity test must be Done before start of every Course of ttt only

4-procaine pencillin

< 4 years 1 vial > 4 years 2 vials Every day as asingle dose Or in 2 divided doses For 7 days

Pencillin procaine vial 400.000 unit /vial

[9]

B-broad spectrum pencillins

Gram +vebut notantistaph Gram-vebut Not Antipseudomonas Not Antiklebiella 60-90mg/kg/day every 6-8 h -Epicocillin (20-30mg/kg/dose) Ampicillin In meningitis 150-200 susp125-250mg/5ml mg/kg/ Day vial500-1000mg/vial Main side effects are : -diarrhea -skin rash e Infectious Mononucleosis

Ampicillin

Ampicillin+ sulbactam Amoxicillin

unasyn,unictam,ampictam oral50 mg/kg/day susp 250 mg/ 5ml i.e 1 cm/kg/day every 8 H -unasyn,unictam,sulbin parenyral150mg/kg/day vial 375,750,1500,3000 mg / vial -Drops 60-90 mg /kg /day every 8 h hiconcil 100mg/ml Less side effects than (20-30mg/kg/dose) -Susp Ampicillin Oral, iv, im Biomox 125-250 mg/ 5ml Ibiamox 200-400mg/5ml -Vials e-mox 250-500-1gm/vial 60-90 mg/kg/day (20-30mg/kg/dose) Orally every 8 h -Hibiotic-N susp Contraindicated before 9 230 460 mg/5ml Months old d.t GIT -Megamox,deltaclave susp troubles 228.5 457 mg/5ml -Augmentin , curam susp 156312 mg/5ml -Augmintin ,magnabiotic 600 mg &1,2gm vial -Amox+flucloxacillin e.g flumox susp 250 vial 500mg &1gm cap 250 ,500 mg -amox+cloxacillin amox+dicloxacillin

Amoxicillin +Clavulinic acid

30 mg/kg/day Iv only every 12 h C-Pencillin Combinations 100-200 mg/kg/day

Oral preparation has bad tast njection form very painful

[10]

D-other pencillins piperacillin pencillinase resistant pencillin

200-300mg/kg/day 8-12h Im or iv Cloxacillin Dicolxacillin Flucloxacillin

pipril vial 2gm & 4gm

Same spectrum as ampicillin

+antipseudomonas

Cephalosporines A-first
generation
1-cephradine
60-90 mg/kg/day every (20-30mg/kg/dose) Oral ,iv, im

6-8 H

Ceporex , ospexin ,keflex Susp .125 &250 mg /5ml Ceporex tab 250 ,500 ,1000 mg Ceporex vial 500 , 1000 mg

80% Gram +ve 20% Grame ve

2-cephradine

60-90 mg/kg/day every (20-30mg/kg/dose) Oral ,iv, im

8H

Velosef ,cephradine ,cefadrine Susp125 &250 mg /5ml Cap250 ,500 ,1000 mg Vial250 ,500 ,1000 mg Farcocef vial only 250&500mg

[11]

50 mg /kg /day every

3-cephadroxil

12 H

Orally -In case of susp 250 Dose=wt/2 every 12h -In case of susp 250 Dose=wt every 12 h

Duricef , biodroxil Susp125 ,250 ,500 mg/5ml cap.500mg N.Bcurisafe drops 100mg/ml

B-second
generation
1-Cefruxime
Oral 20-40mg/kg/day Every 12 H parentral50100mg/kg/day every 12 H IV or IM 20-40mg /kg/day every 8 H (10 mg/kg/dose) orally

Zinnat - Susp..250mg/5ml - Vial.750 &1500mg

50% Gram +ve 50% Gram -ve

2-Cefaclor

Dose=wt/5 every 8 H
3-Cefprozil
20-40mg/kg/day every 8H

In case of 250mg susp

Bacticlor 60 ml -susp125 &250mg/5ml ceclor75 ml -125&250mg/5ml

Cefzil susp 125&250mg/5ml

[12]

C-third generation
ceftriaxone

50-75 mg/kg/day single daily dose Ivwith water IMwith lidocaine Available in to forms one for IM injection& the other for IV injection

Cefaxone vials

2508 50014 1000..20 Oframax vials 250.8 500.22 Ceftriaxone sandoz 250..9 5000.18 1000.29

80% Gram ve 20% Gram +ve &antipseudomonal Active agaist gram+ve& Gram ve but not Antipeudomonal

cefotaxime

100-150mg/kg/day every 12 H IV oR IM 100-150mg/kg/day every 12 H IV oR IM 100-150mg/kg/day every 12H IV oR IM

Xorine vial &1gm Cefotax , claforan vial 1/4 , 1/2 & 1 gm Limited use in pediatrics Cefobid & cefazone vial affect 1/2gm & 1 gm spermatogenesis&can Cause testicular atrophy Fortum vial 1/4 , 1/2 & 1gm Most potent against pseudomonas

cefoperazone

ceftazidime

[13]

oral 3rd generation

cefixime
8 mg/kg/day single dose or in 2 divided doses Ximacef &suprax Susp 100mg/5ml cap 200mg/cap Not antistaph Not antipseudomonal Used mainly in ttt of Uti , typhoid fever, OM& sinusitis

cefpodoxime D-fourth generation 1-cefpime

1o mg/kg/day in 2 divided doses 50-100mg/kg/day 1n 2divided dose

Orelox susp 40mg/5ml Tab 100mg Wincef vial.. 1/2 gm(14) 1gm(21) More extended spectrum than 3rd gen

2-cefepime

50-100mg/kg/day 1n 2divided dose

Maxipime 1/2&1 gm Cefrom 1/2&1 gm

vials

aminoglcosides
gentamicin
5-7 mg/kg/day 1n 2-3 divided Doses IV oR IM -Garamycin amp 20 & 80 mg/2ml 40 mg/ml -Epigent amp 20 & 80 mg /2 ml -gentamycin amp 20 & 80 mg/2ml 40 mg/ml
[14]

mainly Gram-ve + Antipseudomonal + Weak Anti staph

Most nephrotoxic(reversible) Especially: -When taken e other nephrotoxic Drugs -in renal patient

amikacin

10-15mg/kg/day 1n 2 divided Doses IV oR IM

Amikin vial 100 , 250 ,500 mg/2ml

Widest spectrum Most ototoxic(irreversible) Both auditory&vestibular

tobramycin

2.5-7.5mg/kg/day in 2-3 divided Doses IV oR IM

Nebcin vial 20 &80 mg/2ml

Most active against pseudomonas

N.B

1-amnoglycosides should not be used more than one week otherwise evaluation of renal function Must be carried out 2- amnoglycosides not used in ttt of meningitis as it do not cross blood brain barrier 3-no oral form as no absorption from GIT

macrolides
Erythromycin

30-50mg/kg/d Every 6-8 H Orally

-Erythrin & erythrocin Susp 200mg / 5ml -Eryped susp 400mg/5ml N.Bpresent in some

Gram+ve mainly Active against atypical Organisms(no cell wall) e.g mycoplasma, Chlamydia campylobacter

combination e.g pedizole susp (+ SMX 600mg) primomycin susp(+ TMP 50mg)

Clarithromycin

15mg/kg/day Every 12 H Orally After meal

Klacid susp..125 &250mg/5ml Klarimix susp125mg/5ml

[15]

Azithromycim

10mg/kg/day
Every 24 H Orally On empty Stamch

Zisrocin susp (30ml) 100mg/5m Although ttt for 3 days Xithrone susp(15ml). only it Remain in tissue in 200mg/5ml effective Concentration Zithrodose(45ml)..100mg/5ml for 10 days In case of 100mg susp Dose = wt 2 per day In case of 200mg susp Dose= wt 4 per day

Spiramycin Roxithromycin

[16]

0ther antibiotics
t\Tetracycline

2550 mg/kg/day in 24 divided doses.

Vibramycin Doxy SR Cap...100mg/cap

-Contraindicated before 8 years old -Mainly in.. brucella, Chlamydia &Mycoplasma infection
N.B----may be used in Sinusitis (ambrodoxy cap)

chloramphenic 50-100mg/kg/day ol Oral IV IM Every 8 H

Mephenicol Cidocetine Vial--1gm Susp--125mg Supp--125&250

-Contraindicated before 6 years old (bone marrow depression)

-Mainly in.. Meningitis Typhoid fever

sulphamethoxazole Trimethoprim

4mg tmp+20mgsmx/kg/day In 2 divided doses

Septrin, Septazol & Sutrim susp

(200mgsmx+ In susp form--1cm/kg/day every 12h 40mgTmp)

clindamycin
20-40my/kg/day Every 8-12 h Oral IV IM

Mainly in.. -UTI -GE

-Dalacin c

Mainly in Amp150,300,600 anaerobic infection Cap... 150 , 300 mg &antistaph -Clindam (e.g dental infections)
Cap150 , 300mg

Quinolone

-Ciprofloxacin In neonates ?? 10mg/kg/day Infant&children 15-30mg/kg/day - Ofloxacin completely Contraindicated in In pediatrics

Not recommended before 16 years N.B---topical preparations are safe In all ages

[17]

Nitrofurantoin :

Dose----5-7mg/kg/day rvery 12 H after meals (food its absorption by 40%) Preparations------uvamin retard cap 100mg/cap macrofuran&mepafuran cap 50 &100mg/cap N.B- 1-mainly in uti 2-In long term use(uti prophylaxis) may cause peripheral neuritis so Consider Vit B compl 3-Like other nitrofuran(nifruxazide(antinal)&furazolidon) is contraindicated in favism

Choice of antibiotic by system

- URTI -amoxycillin , amoxicillin clavulinic acid ,ampicillin sulbactam - 1st generation cephalosporin -2nd generation cephalosporin -LOWER RESPIRATORY TRACT INFECTION -3rd generation cephalosporin -2nd generation cephalosporin - Amoxicillin clavulinic acid - SMX-TMP -CEFTRIAXONE -CEFOTAXIME -XIMACEF

-GIT INFECTIONS(GE)only with:

patient looks toxic salmonella,shigella,campylobacter patient in shock(no time to wait) parentral GE

-UTI -Nitrofurantoin -SMX-TMP -3rd generation cephalosporin -1st generation cephalosporin(cephadroxil) -Aminoglycosides -SKIN INFECTION -Macrolides -2nd generation cephalosporin -3rd generation cephalosporin -OSTEOMYLITIS -antistaph e.g Cloxacillin , Flucloxacillin(Flumox 200mg/kg/day) or Vancomycin(Vancocin 40-80mg/kg/day) + Fortum ,Ceftriaxone or Cefotaxime
[18]

ANTIBIOTIC SELECTION BY AGE GROUPS

1-Amox-clavcontraindicated before 9 months(GIT troubles) 2-Chloramphenicol. contraindicated before 5 years(bone marrow depression) 3-Tetracyclincontraindicated before 8 years 4-Ofloxacin contraindicated before 12 years(osteoarthropathy)

How to calculate dose of antibiotic?

In suspension form
- Required Dose in ml =

amount required in mg/kg/dose body weight 5(spoon)

Concentration of susp(125 or 250 . etc )

5 )250 125(

Example : Child 15kg weight how to calculate dose of bacticlor 250mg ? Answer : Required Dose in ml = 30(dose in mg/dose) (15)body weight5(spoon) = 3 ml 250(Concentration of susp) So the required dose = 3ml every 8 hours

In injection form
-Required dose in ml= Amoun Required in mg/kg/dosebody weightamount in which you dissolve Concentration(250 or 500 or 1000 mg .etc)

[19]

Respiratory system

[20]

Respiratory system
Drugs of respiratory system

1-decongestants
A-local

allowed after 3 months old

1-2drops in each nostril Every 12 h For5days only Afrin-ped N.D Iliadin merck-ped N.D Long acting So used every 12 H

Oxymetazoline

Xylometazoline

1-2drops in each nostril Every 8 h For5days only

Otrivin-ped Balkis-ped Rhinex-prd

Short acting So used every 8H

Naphazoline

1-2d/8-12H

Nostamine

Nasal&eye drops

N.B

1-from 6 years old use adult nasal drops 2-if loca decongestant has to be used for long period every 5days stop ttt for2 weeks 3-nasal saline can be used in newborns&infants < 3 months preparations Lyse nasal drops Otrivin baby saline nasal drops Salinol nasal gel Physiomere nasal drops (40 ) dose1-2 drops in each nostril /before feeding
[21]

B-systemic
-Decongestant only Sudophine syrup Dose in all preparations -1-2 years2,5cm tds ->2 years5 cm tds

-Decongestant+antihistamine Actifed syrup Sine up syrup Balkis syrup Triaminic drops

-Decongestant+antihistamine Congestal ,cometrex Michaelon ,dolo-d Dose in all + antipyretic Brufen flu preparations -1-2 years2,5cm tds ->2 years5 cm tds

N.B
1-start with use of local decongestants and if failed to improve Condition use systemic decongestants 2-systemic decongestants are contraindicated in bronchial asthma &bronchitiscause dryness of secretions 3-abuse of systemic decongestants can cause severe irritability&crying Especially rhinostop drops 4-preparation contaning phenyl propanolamine aracontraindicated in Pediatrics e.g.noflu,antiflu,flurest,flustop,rhinomol syrup

[22]

2-Cough preparations A-Hebal preparations for dry cough : - sina dry (9,90) - balsam(7,45) - herba cough(9,75) - tussinor(6,75) Dose < 1 year ..2,5 cm tds > 1 year..5 cm tds B-chemical preparations for dry cough: -selgon(pipazethate) Dose1-2mg/kg/day Preparations..drops 1 drop/kg/day supp10mg/supp tab20mg/tab -paxeladine or oxeladine Dose..1-2mg/kg/day Preparations..syrup10mg/5ml capsule40mg/cap N.B Although it suppress cough it do not interfere with Expectoration so allowed in asthma -silomat(clobutinol) Dose..1-2mg/kg/day Preparations..drops 1 drop/kg/day syrup5 cm/kg/day tablet 40mg/tab N.B Although it suppress cough it do not interfere with Expectoration so allowed in asthma -dextromethorphane Dose.1-2mg/kg/day <1year..2,5cm/tds ->1year..5cm tds Preparations.codilar, tussilar ,tussivan-n syrup C- suppositories for dry cough: selgon the best rectoplexilcontain antihistamine eucapholsome claim that it cause hyperpyrexia cough seed infantil supp.cotain 100mg paracetamol children supp. cotain 250mg paracetamol

[23]

N.B
-Cough suppressants are should not be used with productive cough retention of secretions in chest -Exceptcough is severe ,distressing ,preventing baby from sleep used as asingle dose at night (mainly supp)

3-mucolytic expectorants
A-herbal preparations: -preparations e mild mucolytic expectorant effect: Fast(7) ,Thymy(5) , Thymotal(9.75) ,Formix(6) -preparations e moderate mucolytic expectorant effect: Sina wet ,Broncare ,Alveoline , Bronche ,Pentamix ,Babe tone -preparations e strong mucolytic expectorant effect: Broncho syrup( ) Dose in all preparations-------< 1 year 2,5 ml / > 1 year 5 ml / B-Chemical mucolytics -Bromhexine Dose..,5-1mg/kg/day Preparations....DropsBisolvone drops SyrupBromhexine , Bisolvon 4mg/5ml Tablet Bromhexine , Bisolvon ,Solvin 8mg/tab -Ambroxol Dose..1-2mg/kg/day Preparations....DropsAmbroxol ,Mucosolvan 1 drop/kg/day yrupMuco , Mucosolvan weight/2 per day TabletAmbroxol -Cabocisteine Dose..10-20mg/kg/day PreparationsRhinathiol 100mg/5ml Mucosol 125mg/5ml Mucolase , Ultasolvin 250mg/5ml C-Non herbal expectorants: Bronex drops Avipect , Koffex ,Expectyl , Pulmonal-n ,Actifed expectorant syrup Phenergan expectorant syrup
[24]

N.B
1-try to avoid preparations contaning antihistamines or decongestants As it cause dryness of secretions e.g toplexil syrup 2-the best mucolytic agent is water i.e fluid intake during illness 3-the therapeutic value of the drugs Is doubtful &there is no critical Choice BW different preparation

4-Bronchodilators:
A- adrenergic agonists oralSalbovent,Salbutamol Salbutamol oral,1-,2mg/kg/day inhalation100-200 mcg/dose ventolin neubilizer,1-,3ml/kg/dose (2mg/5ml) inhalationVental inhsler Ventolin evohaler (100mcg/puff) Terutaline oral,1-,2mg/kg/day inhalation200mcg/dose oralAironyl ,Bricanyl (1,5 mg/5ml) inhalationBricanyl inhaler (200mcg/puff) Brotec syrup

Fenoterol

N.B 2 agoinsts should not be used continuosly for more than 2 weeks
Other with adaptation of receptor occur & discotiuation of drug Should be done Although B2 receptors become fully developed at 12-18 months B2 agoinsts can be used before this age because receptors Are present but its sesitivety is low which improve gradually By time -some patients may not respond well to salbutamol &respond Trebutaline &vice versa

[25]

-B2 agoists are present in combination with 1-Expectorants e.g .ventolin expectorant Farcolin , Bronchovent , Octivent , Brozedex 2-Mucolytic &Expectorants e.gOsipect , Allvent B-other adrenergic agonists: -isoprenaline sulphate Effective in patient < 1 year Alubent syrup Dose.1 cm/5 kg/day orally -adrenaline Dose.,01mg/kg/dose S.C Prepationsadrenaline amp(1mL) 1mg/ml

C-xanthines:
Theophyline aminophyline
Ivonly

oral15-20mg/kg/day

oral mucophyline (100mg/5ml+bromhexine)

Dose=weigt /day 6

-If other therapy has failed

- In icu where serum level Can be monitored Loading dose.6mg/kg over 30 min (provided no theophyline in last 24 H) maintenance.,5-1mg/kg/H (if theophyline is given in last 24H)

Farcosolvin ( &)trisolvi
(50mg/5ml+ambroxol+ guaiphensin)

Dose=weigt /day 3 Minopyline,Etaphyline

Amriphyline100mg/5ml

Epicophyline(125mg/5ml)

supp
Etaphyline, Amriphyline
(100mg/supp)

Minopyline,farcophyline
(125mg/supp)

parentral
Minopyline(125 , 300, 500) 5ml 2ml 3ml Etapyline (500/5ml)
[26]

Diseases of respiratory system

A-common cold
symptoms: -Runny nose ,sneezing -Mild fever ,mild cough -Irritability...in neonates&young infants -Sore throat.in older children Signs: -Mild congested throat +Edematous uvula

Treatment: neanates &young infants: -normal saline nasal drops -herbal preparations +antipyretics(paracetamol) +antihistamines(fenistil) .in severe cases ..provided free chest
Example Lyse nasal drops
2-1

Flucease syrup 3 2.5 Tempra syrup 8 2 + Fenistil drops infans > 3months: - use pediatric nasal decogestants > 1 year: you can add systemic decongestant Example Afrin ped nasal drops 5 12

+ Congestal syrup + Dolphin 12,5 mg supp N.B See drugs of respiratory system (decongestsnts)

[27]

B-allergic rhinitis

Treatment: prophylaxis:

symptoms: -Avoidance of PPT factors -paroxismal attack of: Ingestants (specific diet) watery nasal discharge Inhalants (dust) prominent sneezing&ithing in nose Ingectants (specific druge) -allergic manifestation else where -Mast cell stabilizers in Body Nasotal nasal drops -no fever 3- Signs: -pale nasal mucosa +Antihistaminescetrak syrup -hypertrophied turbinates curative: --- -systemic anti histamines ) 4-3( -nasal corticosteroids in resistanyt cases DD: Example Vasomotor rhinitis(wet type) Cetrak tab Flixonase nasal spray(27.5) Beconaz nasal spray 12 2 N.B
Local CST should not be used < 6 monthOld Systemic CST are of no role in allergic rhinitis

[28]

C-sinusitis
symptoms: -high fever especially acute sinusitis -mucopurrulant nasal discharge & Nasal obstruction -prolonged cough >2 weeks Providedmid night or early Morning cough free chest -pain over affected sinus -headache(in children > 4years) Signs -post nasal discharge greenish or deep yellowish -thick puurrulant nasal discharge on inferior turbinate -tenderness over affected sinuses may be abscent

Treatment:
-Nasal decongestnts -Analgesic antipyretics -Antibiotics +Mucolytics (with viscid secretions) Example -Afrin ped nasal drops 5 12 -Brufen 8 2 Or dolphin 12,5 mg supp -Bisolvone tab or ambrodoxy cap -choice of antibiotics Amoxycilline Amoxycilline clavulinic acid 2nd generation cephalosporines e.g Cefruxime

N.B
There are4 paires of paranasal sinuses 1-Ethmoid 2-maxillary both are present at birth &continue To grow until puberty 3-frontaldo not develop before age of 7y 4-sphenoidnot fully developed before Adolescent

7 If you examine for tederness over frontal Sinus ----

[29]

D-otitis media
-a common cause of fever without a focus

-very common in pediatrics because: Eustachian tube is shorter ,narrower More straight So easly obstructed by: Common cold d t mucosal oedema Milk d t feeding in recumbant position Treatment: Types: 1-First line ttt Acute suppurative O.M: In first 48H with mild fever &mild 1-stage of E.T obstruction pain By : complaintmild deafness 1-decongestant nasal drops examinationmild drum retraction 2-analgesic anti-inflammatory (-ve pressure in middle ear) (paracetamol not anti-inflamatory) 2-stage of catarrhal O.M +systemic decongestants complaintmild fever,mild earache (with out antihistamine ?) deafness Example examinationcongested drum Afrin-ped nasal drops 3-stage of suppuration 5 12 -before suppuration: Dolphin supp symptoms Or catafly syrup high fever,severe throbbing pain Or brufen syrup signs 2-2nd line ttt bulging drum +severe congestion if complaint is severe from start with pale center (high fever &severe pain) -after perforation: If You reevaluate after 48-72H symptomsmucopurrulant ear With no improvement discharge pain By1-as above signsdrum perfpration , 2-start antibiotic therapy discharge in E.T Amoxycillin 90mg/kg/day 4-stage ofresolution: Amoxycillin clavulinic acid Otorrhea & deafness gradually 90mg/kg/day within 3-4 weeks Cefruxime 50mg/kg/day Cefpodoxime10mg/kg/day orally

[30]

Reevaluate after 48-72H if improving contiue AB for

10dayss
3-3rd line of ttt If not improving after 48-72H from 2nd line by 1-Ceftriaxone50-75mg/kg/day single daily ingection for three days 2-Diagnostic tympanocentesis c&s test

N.B
Topical ear dropsusually comind AB+CST Neopred-p, Dextratrol Ciprocort ,dexaron plus ,FML Neo (Of no role if drum is intact)

B-chronic suppurative O.M: C/P there is persistant discharge& perforation for more than 1 month types : 1-tubotympanic Perforationcentral Dischargeprofuse, M P non fetid 2-atticiantral Perforationin pars flaccida Dischargescanty,purulent,offensive C-secretory O.M(chronic non suppurative) D.T long standing obstruction of E.T adenoid chronic tonsillitis allergic rhinitis Symptoms hearing loss , recurrent earache Signs retracred drum

TTT A-Medical:
1-Ttt of PPT factors e.g adenoidectomy

2-Decongestant nasal drops 3-Anti-inflammatory e.g

Maxilase syrup

4-Mucolytics 5-AB for 10 days A-Surgical: Myringotomy &Grommets tube

[31]

E-croup
A-acute infectious croup

1-acute viral laryngitis

age1-3 years symptomshoarsness of foice brassy cough mild fever signs-mild stridor i.e abscent during rest e.g sleep&appear e crying -mild fever +congested throat

treatment: 1-Inhalation of steam medicated e tinnture Benzoin 2-TTT of nasopharyngitis. + Antihistamine + Cough suppressant at night Example Vapozole solution ) 5(
8

Brufen syrup +Cetrak syrup

N.B
Volatile oils can be used e.g Flonaze cap or pulmix cap

Treatment -As above 2-acute laryngio-tracheo-bronchitis -Herbal mucolytic expectorant +Antibiotics(if patient looks toxic) symptomsas above +Cough suppressant at night +dyspnea+expecroration Example signsmoderate fever -As above stridor biphasic -Broncho syrup i.e inspiratory&expiratory N.B +Bacticlor susp or Ibidroxil susp

grades of stridor:
grade1 stridor during exertion i.e crying grade 2stridor at rest grade 3stridor+ retraction grade 4strdor+cyanosis

N.B

[32]

3-acute epilotitis
Ageugually . 3 months symptomssudden onset &rapidly progreesive course of : -high fever -severe malaise -severe stridor -drolling of saliva signs

pharyngeal examination is absolutely contraindicated

cause reflex vagal stimulation &cardiac arrest IXlateral soft tissue X ray on neck thumb sign

Treatment: A-Hopitalization B-Tracheostomy or endotracheal intubation In profound cases C-Medical ttt: 1-02 2-adrenaline neubilizer Dose ...,1ml/kg/dose of 1:1oooo N.B solution +2 ml saline Every 2-4 ( 2 ) 3-corticosteroide hydrocortisonesolucortef vial 1 cm/10kg/6h IV or IM dexamesthasonedecadron 1 cm/10kg/8-12h IV or IM
N.B

(Inhaled CST are far more effective if

available)

4-antibiotic-----on

maximum dose

Cefruxime150-200mg/kg/day OR Ceftriaxone100mg/kg/day +Amoxycillin 300mg/kg/day 4- Mid night croup 5-antipyretics anti-inflammatory Treatment: -Its allergic or viral condition During attack symptoms&sign -Adrenaline neubilizer Child with nasopharyngitis develop -corticisteroide Solucortef vial an attack of croupy cogh&stridor Segmacorten vial Attack subside with few hours Then By the day the child is normal -Vapozol solution Attack my be repeated in next Few -Antihistamines nights

[33]

5-laryngeal F.B
Previously normal child suddenly Develop cough , chocking , stridor

Treatment: ENT referal Treatment : 1-Herbal mucolytic expectorants 2-Bronchodilators + Antipyretics + Nasal drops Example: Fast or broncho syrup Ventolin syrup + Brufen syrup + Iliadin meck ped nasal drops

F-bronchitis
-most common cause of acute cough in

pediatrics

-mostly viral Symptoms

-History of common cold for 3-4 days -Cough dry then productive

+ Fever + Vommitting (post tussive) signs -Abscent respiratory distress -Harsh vesicular breathing coars +Coarse Creptition+sonorous rhonchi
N.B

N.B
-try to avoid use of declophenac Preparation as it my cough ( cause bronchospasm) TTT As above + bronchodilators i.edose (4 times/day) Or use 2 drugs

Cough may persist for 2week

G-wheezy bronchitis
previously called asthmatic bronchitis symptoms & signs as above plus sibilant rhonchi

N.B

Antibiotics do not affect course

cough When to use antibiotics? -Fever is persistant -Patient looks toxic -Sputum is purelan What is the Choice of antibiotic? -Amox-clavulinic acid 20-30mg/kg/dose nd -2 generation cephCefaclor 10mg/kg/dose Every 8 hours
[34]

Acute bronchiolitis
Treatment: 4H -actue viral infection that affect small 1-Hospitalization of severe cases Bronchioles causing there partiel 2-Humidified o2 age most Obstruction respiratory distress important -caused by respiratory sencitial virus 3-Hydrationoral OR iv -age 3months-2 years e peak around 4-Hydrocortisone(drugs) 6 months a-Bronchodilators2 agoinsts Symptoms even under 1 year First.common cold (nasopharyngitis) (inhalated 2 agoinsts are more Fever,runny nose, for 2-3 days effective) Then..rapid development of moderate to b-Hydrocortisonecan be used Severe dyspnea,cough,wheezing as asingle at night e.g: Feeding difficults -Sigmacorten vial (400mg/vial) Finally.improvent within few days -Solucortef vial (100mg/vial) signs -respiratory distress ( tachypnea, working ala nasi, retraction,Grunting , cyanosis) -Auscultation: Diffuse sibilant rhonchi Harsh vesicular breathing e prolonged Expiration +Fine creptition at end of inspiration X ray Hyperinflation + are of segmental collapse

[35]

Tonsillitis
Age uncommon before 1year Peak incidence at 4-7years of age Etiology In children<2year.mostly viral In children>5yearsmostly bacterial C/P viral tonsillopharyngitis: -History of....rhinorrhea,conjunctivitis,cough Or hoarseness of voice -Fever.is low grade(~38c)or high grade(~40c) -In younger infantsirritability,refusal of feeding -In older childrenmoderate sore throat,dysphagia -Throat examination...mild erythema of tonsils&pillars +Small ulcers on soft palate No pus follicles , no membrane Streptococcal tonsillopharyngitis: -Fever.moderate fever(~38.5-39.5) -Severe sore throat&dysphagia -vomitting & abdominal pain(dt mesenteric adenitis) -Throat examination... diffuse erythema of tonsils&pillars +pus follicles or membranous exudates -Anterior cervical lymphadenopathy anterior cervical L.N are enlarged&tender

Treatment: -Soft diet -Excessive warm fluids -Analgesics antipyretics +Decongestant nasal drops Example -Brufen syrup wt/2every6-8H OR Dolphin supp +iliadin merck N.D Treatment: -As above -Antibiotics Choice of antibiotic -amox &amox-clavulinic acid -ampicillin sulbactam -first generation cephalosporin -pencillin(oral - procaine)
N.B

N.B
-tonsillitis or pharyngitis is the most over- diagnosed condition in pediatrics -tonsillitis or pharyngitis is rare uncommon below2 years

-no need for AB in viral tonsillitis -no need for parentral AB in Bacterial tonsillitis -3rd gerneration cephalosporins Are Not effective in tonsillitis (week anti gram +ve) -AB should be used for 7 days even the child had improve -mouth gargles can be used in older childrens e.g
Antiseptol M.W (usede`outdilution)

Betadine M.W
[36]

Chronic tonsillitis:
-Shape..irregular(d.t fibrosis) -Size..unequal( or) -Pharynx..congested(especially anterior pillar) -Cervical lymph nodes.persistant enlargement -On pressing ant pillar(by tongue depressor) oozing of pus from crypts -Halitosis

Indication of tonsillectomy: -Repeated attacks of acute follicular tonsillitis

(> 7 attack per year or >5attacks in 2 years) -One attack of peritonsillar abscess -Chronic tonsillitis -In association with of adenoidectomy -Previous documented history of rheumatic fever -Tonsillar tumors -Tonsillar forgein body

[37]

Bronchial asthma
Definition -chronic inflammatory disorder of the airway that cause recurrent episodes of wheezing,breathlessness,chest tightness and coughing particulary at night or early morning in susceptible individuals -these episodes are associated with: wide spread airway obstruction of variable degree revesibility of this obstruction either spontaneously or as result of ttt increase in existing bronchial hyper-responsivness to a variety of stimuli Clinically symptoms 1-Wheezing high pitched whistling sound when breathing out is the cardinal sign Wheezing however may be abscent in severe cases d.t. the small tidal volum 2-Cough which worsen by night & is unproductive early in the attack 3-Difficulty of breathing 4-Chest tightness
-in severe cases the child may be unable to walk or talk and may assume a hunched over

Sitting position(i.e bent or curved position)which make it easier to breath -symptoms occur /or worsen at night or early morning ,walking the child from sleep - symptoms occur /or worsen in presence of triggers of asthma - eczema,allergic rhinitis or family history of asthma or atopic disease are often present

Cough variant asthma

Some cases of asthma present with recurrent cough particularly at night with no wheezing They respond to B-agoinsts and/or steroid

Consider that in children -Wheezing does not always mean asthma -Asthma may be present without Wheezing(silent chest)

signs -Tachpnea ,tachycardia -Hyperinflation of the chest -Signs of respiratory distress e.g nasal flaring, intercostals&suprasternal retraction Cyanosis in severe cases
[38]

Clinical grading of acute asthmatic attacks:

-Grade1(mild acute asthma)wheezing only Prolonged expiration&expiratory wheezing only No respiratory distress or diminished air entry -Grade2(moderate acute asthma) wheezing+tachypnea Prolonged expiration&expiratory wheezing Rapid respiration(tachypnea) & slight diminished air entry -Grade3(severe acute asthma) wheezing+retraction Prolonged expiration&expiratory wheezing Tachypnea,retraction(intercostals,suprasternal) & moderate diminished air entry -Grade4(profound acute asthma) wheezing+cyanosis Rapid respiration,marked retraction and cyanosis Markedly diminished air entry Silent chest(minimal or absent wheezing) Management: Management:

A-Treatment of acute attack of asthma: Assess severity

(see clinical grading of asthma)

Intial treatment Inhaled short B2 agoinst(Farcolin)up to 3 times with15 min apart ,3cm/10kg + Anticholinergic(Atrovent) 1cm/10kg once

Good respond =mild episode

Incomplete response =moderate episode

Poor response =severe episode

[39]

B-Then

1-Mild to moderate attack: Use one or two bronchodilator at home 1-B2 agoinst:(the best ttt)
-Salbutamol Inhalation100-200 mcg/dose(vental inhaler ,ventolin evohaler100mcg/puff) Oral,1-,2mg/kg/day(salbovent,salbutamol, ventolin 2mg/5ml) -Terutaline Oral,1-,2mg/kg/day(aironyl ,bricanyl 1,5 mg/5ml) Inhalation200mcg/dose(bricanyl inhaler 200mcg/puff)

2-Theophyline: Mucophyline (100mg/5ml+bromhexine) Dose=weigt /6 /dose Farcosolvin & Trisolvin (50mg/5ml+ambroxol + guaiphensin) Dose=weigt /3 /dose

2-Severe attack (hospital management)

A-Neubilizer:
Neubilizer + 4H In emergency departement Farcolin ,3ml/10kg+2ml saline can be repeated for 3 times with 15 min apart Atrovent(250mg/2ml).... 1ml/10kg+2ml saline for one time Combivent(Farcolin+Atrovent)1ml/10kg/dose can be used from start In hospitalfarcolin is given every 2-3 h then every 4-6-8 h as patient improve

B- 4 H:
-Hospitalization( better in icu) -Hypoxia ttt oxygen by face mask or nasal prongs(better heliox=70%helium+02 30%) -Hydration IV fluid to prevent dehydration(excessive H2O vapor loss dt tachypnea) -Hydrocortisone every 6 hours for 2-3 days only Dexamethasone ,4mg/kg/dose (1ml/10kg iv) Solucortef 5-10mg/kg/dose (1ml/10kg iv) Solumedrol 1mg/kg/dose -AB.for fear of nosocomial infection (antigram +ve &antigram -ve)

[40]

N.B
IV AminophylineMinopyline(125/5ml , 300/2ml, 500/3ml)& Etaphyline(500/5ml)only : - In ICU where serum level Can be monitored Loading dose.6mg/kg over 30 min (provided no theophyline in last 24 H) maintenance.,5-1mg/kg/H N.B

-If other therapy has failed

What is The best manner of home management ?

1-Inhaled B2 agoinsts (should be used with spacer) e.g Ventolin evohaler () 6 8 12 2-Inhaled corticosteroids: (should be used with spacer) e.g Beclosone inhaler ( ) 8 2 N.B ) ( 12 2 -Combined B2 agoinsts+corticosteroids inhaler not to be used before 12 years old e.g Clenil inhaler -Why therapy is preferred &has many advantages over oral Medications? 1-Onset of action far more rapid (in 2-3 min) compared 20-30 min in oral 2-Peak bronchodilator effect is greater 3-Dose much smaller ( < 10% of oral equivalent) so less side effects 4-Far more effective in blocking exercise-induced bronchospasm

[41]

C-Long term control stepwise drug therapy: Long term control Step 1 Intermittent asthma Step 2 Mild persistant asthma No daily long-term medications Short acting 2 agoists PRN Low dose inhaled corticosteroids OR Other alternatives: -oral leukotriene modifiers -oral sustained release theophyline Step 3 medium dose Inhaled steroids OR Moderate persistant asthma Other alternatives: low dose inhaled steroids+either -Inhaled long acting B2 agoinsts -oral leukotriene modifiers -oral sustained release theophyline high dose Inhaled steroids Step 4 Plus one of the following: Severe persistant asthma
-Inhaled long acting B2 agoinsts - oral leukotriene modifiers -oral prednisolone -oral sustained release theophyline

-the above mentioned steps therapy should regularly reviewed every 1-6 months for stepping up or stepping down according to Response -rescue course of oral prednisolone can be given at any itme or any step 2mg/kg/day in 2divided doses for 3days(maximum 40mg/day )

Drug

Estimated Comparative Inhaled Corticosteroid Doses

Low Daily Dose Child 0 4 y Child 5 Adult 11 y 80160 mcg

Medium Daily Dose Child 0 Child 5 4y 11 y Adult

High Daily Dose Child 04 y Child 511 y > 320 mcg > 800 mcg 2.0 mg > 1250 mcg Adult > 480mcg > 1200mcg NA > 2000mcg

Beclomethasone HFA, 40 or 80 mcg/puff NA Budesonide DPI 90, 180, or 200 mcg/inhalation NA

80240 mcg NA NA

> 160320 > 240480 mcg NA mcg > 400800 > 6001200 mcg mcg NA NA > 1.0 mg NA NA

180400 180600 mcg mcg NA

Budesonide inhaled suspension for 0.25 0.5 mg nebulization, 0.25-, 0.5-, and 1.0-mg dose 0.5 mg Flunisolide, 250 mcg/puff Flunisolide HFA, 80 mcg/puff Fluticasone HFA/MDI, 44, 110, or 220 mcg/puff Fluticasone DPI, 50, 100, or 250 mcg/inhalation Mometasone DPI, 220 mcg/inhalation Triamcinolone acetonide, 75 mcg/puff NA NA 176 mcg NA NA NA

> 0.51.0 1.0 mg mg NA NA

500750 5001000 mcg mcg 160 mcg 320 mcg 88176 mcg

1000 > 10002000 1250 mcg mcg 320 mcg > 320640mcg

640mcg > 640mcg > 352 mcg > 400 mcg NA > 900 mcg > 440mcg > 500mcg > 440mcg > 1500mcg

88264 mcg > 176> 176352 > 264440 mcg > 352 352 mcg mcg mcg NA NA NA >200400 >300500mcg mcg NA 440 mcg > 600900 > 7501500 mcg mcg NA NA NA

100200 100300 mcg mcg NA 220 mcg 300600 300750 mcg mcg

DPI, dry powder inhaler; HFA, hydrofluoroalkane; MDI, metered-dose inhaler; NA, not available (either not approved or no data available or safety and efficacy not established for this age group). [42]

When to give long-term control medications?

medications The asthmatic child is in need of controller medications if has any of the following criteria: 1-If he has asthma symptoms more than 3 times per week 2-If he has night symptoms more than 3 times per month 3-If he need to use more than 3 container of relief inhaler per year

Thethree strikes rulesare used to identify asthmatic children who are in need for controller

N.B
Asthma my be: 1-intermittent..the is no symptoms between the acute attack&chest is completely free It can be classified into: -infrequent intermittent(recur every several weeks or months) -frequent intermittent(recur every few weeks ) 2-seasonal..symptoms develop in certain seasons (inhaled cst can be used during this season) 3-persistant asthma..there is persistant symptoms between attacks It can be classified(according to severity of symptoms) into: Degree of severity Mild persistant Moderate persistant Severe persistant N.B Symptoms of asthma >3 times per week daily continuous Night-time symptoms > 3 times per month >1 time per week More frequent

Oral Mast cell stabilizers (ketotifen)

Dose ,05mg/kg/day in 2 divided doses (5ml OR 1 Tab /20kg/day) PreparationsZaditen Ketoti-Zylofen Syrup 1mg/5ml Zaditen Ketoti-Zylofen Tab 1mg/Tab Side effectsdrowsiness ,increase appetite No longer recommended in asthma TTT Can be tried in preschool children with mild persistant asthma

[43]

Inhaled corticosteroids:
Beclomethasone Dose100mcg/dose TDS (2puffs every8-12h)
Preparations .. Beclosone Becotide inhaler 50mcg/puff

Budesenides Dose ..100-200mcg/dose twice daily

Preparations .. Pulmicort turbuhaler 100&200 mcg/puff

Fluticasone Dose 50-100mcg/dose twice daily

Preparations .. Flixotide inhaler 50&125 mcg puff Flixotide diskus 50&100&250 mcg puff

All inhalation medication are used with spacer or airholding chamber

There are two sizes of spacers in market: -The bluefor children -The orangefor adult

Leukotreine modifiers
Montelukast Dose ..4-10 mg oral once daily every evening
Preparations ..Sachet Singulair sachets 4mg Tab 4mg Kokast ,Singulair ,Clear air (young chilren) Tab 5mg Montekal ,Singulair ,Asmalair (older children) Tab 10mg Montekal ,kast ,Indulair ,Clear air ,Asmalair (adult) N.B

Leukotreine modifiers can be used in non persistant as they decrease frequency of Use of B2 agoinsts inhalers

[44]

GIT
[45]

GIT
GIT DRUGS

antiemetics
1-Domperidone

1 mg/kg/dose N.B 1- Domperidone unlike metoclopromide Do not cross blood brain barrier but You should calculate accurately as B B B is not well developed in pedia 2-in case of vomiting associated e diarrhea You can use motinorm supp after diarrheal Motion 8 3-in GERD Domperidone is given in adose Of 1mg/kg/day 15 min before feeding

Motinorm

Farcotilium Motilium syrup5mg/5ml supp infant 10mg/supp children 30mg/supp adult 60mg/supp tablet10mg/tab

2-Cortigen B6 Suprarenal gland extract + pyredoxine Cortigen B6 (cortisone 50 or 100 mg) (vit B6) Pediatric 50mg N.B--Adult.100mg Cortigen contain cortisone so should be Avoided in patients receiving live attenuated vaccines Ampoules 3-ondansetron 8-15 kg2 mg/dose Zofran4mg(27,5) 15-30 Kg4 mg/dose 8mg(54,2) >30 kg8 mg/dose By IM or IV injection

Danofran4mg(16) 8mg(30)

[46]

4-Metocloprpmide

,5 mg/kg/day -Ampoules.1 ml/10 kg/day -Drops..1 drop/kg/dose -Infantil supp1 supp/10kg/day N.B

Primpran Plasil Amp10 mg/ 2ml Drops,15-,2mg/drop Supp infantile10mg adult..20mg

5-Trimebutine

This drug should not be used in pediatrics Can cause serious extrapyramidal mainfestations C/P convulsion oculogyric movements locked aw torticollis Ttt Akineton Dose.1 mg slowly iv over 20 min Can be repeated e in 20 min Or ..1/2 tab dissolved in acup of Water and give cup Preparation amp5mg/ 1ml tab 2mg/ tab 5-10 mg /kg /day i.e 1 cm /kg /day Gast-reg susp In three divided doses before feeding G-regular N.B Used mainly in GERD

[47]

Spasmolytic & antiflutlents

1-For neonates Dose Pedi-water syrup Aquacure syrup Grip water syrup Dentinox colic syrup Dose.2 drops /kg/dose 4-5 times Before feeding Simethicone drops N.B Dysflatyl drops Baby rest drops Overuse of these drugs can cause Conistipation OR paralytic ileus Spasmotal , babytal drops

2-infant &children A-Visceralgine

,5-1 mg/kg/day Syrup form is what we use in pedia Visceralgine < 1year.2,5 ml /tds berore feeding syrup 10 mg/ 5ml Supp 20mg/supp >1year.. 5 ml /tds berore feeding Tab 50 mg /tab N.B Timogen &spasmofree syrup Tab can be used at 9-10 years old
Farcorelaxin ,5-1mg/kg/day syrup 5mg/ 5ml Syrup..As visceralgine Buscopan Amp1 cm/40kg /day syrup 5mg/5ml Tab 5-8 years....1/2 tab tds before meal Tab 10mg /tab Amp 20mg /1ml > 8 years..1 tab tds before meal Bellacid tab < 2 years..1/2 supp PRN > 2 years..1 supp PRN Spasmin supp

B-Buscopan

C-Bellacid D-Spasmin supp

[48]

Conclusion
syrupfarcorelaxin .2.5 ml if < 1 year or 5 ml if > 1 year supp spasmin 1/2 supp if < 2 years or 1 supp if > 2 years

Antihelminthic drugs
Mebendazole

Oxyuris(100 mg) i.e one tab or 5 ml

once weekly for 3 weeks before breakfast Ascaris (100 mg) i.e one tab or 5 ml & twice daily for 3 days

Anylostoma
N.B

Mebendazole safe from first day of life safe in pregnancy&lactation Albendazole 400mg /day

- Antiver - Anthelmin -Vermin susp100mg/5ml (30ml) tab100mg /tab (6 tab) -Verm 1tab 500mg

Bendax

i.e

susp..100mg/5ml
(30 &60 ml)

2 )3=62 (22 )3=( 12 ) (=

tab..100mg/tab
(6 tab)
Alzental

susp..100mg/5ml

(20ml) Oxyuris 400mg/day single dose /week tab200mg/tab repeated for 3 weeks (6 tab) Ascaris & Ankylostoma Vermizole 400mg/single daily dose susp..200mg/5ml for 3 succesive days (30 ml) Strongloids400mg/day tab200mg/tab before breakfast for 7 days (6 tab) Tenia saginata & Tenia solium 400mg/day before breakfast for 7 days(but poor result) N.B Albendazole not safe before 2 years old not safe in pregnancy&lactation
[49]

Nilosamide

- <11kg body weightnot used - 11-34 kg body weight 1gm(2 tab) first day Then ,5 gm(1 tab)for 6 days ->34 kg body weight 2gm(4 tab) first day Then 1gm(2 tab)for 6 days N.B -used in ttt of
Taenia saginata, taenia soliu& H.nana

Yomesan tab
500mg/tab Niclosane tab 500mg/tab

Praziquantil

Bilharziasis40mg/kg single dose better in middle of fatty meal can be repeated after 1 week Strongloids &H.nana25mg/kg single dose

Epiquantil susp600mg/5ml Distocide & Biltricide tab 600mg/tab

[50]

Conclusion
1-oxyuris

C/P....Ithing around anus especially at night

Drooling of saliva May not appear in stool analysis(need perianal swab at night) Ttt....Anthelmin , Antiver , Vermin 5ml or 1tab /week for 3 weeks Or Alzental 2 tab or one bottle / week for 3 weeks Bendax2 tab or 20ml / week for three weeks Vermizol2 tab or 10ml /week for three weeks

+ +

1-family treatment
2-improve personal hygein of patient i.e -

topically white PPT ointment or any preparation contaning zn oxide 2-ascaris &ankyiostoma TttAnthelmin , Antiver , Vermin 5ml or 1 tab / twice daily for 3 days Or Alzental 2 tab or one bottle / day for 3 days Bendax2 tab or 20ml / day for 3 day Vermizol2 tab or 10ml /day for 3 day 3-strongloids Ttt ..praziquantil25mg /kg single dose.as above Albendazole400mg / day for 7 day Ivermectin150- 200 mcg / single dose 4-t.saginata &t.solium Ttt......Niclosamidesee antihelminthic drugs praziquantil5-10 mg /kg single dose Albendazole400mg / day for 7 day 5-H.nana Niclosamide As above or Praziquantil .25 mg /kg single dose

[51]

N.B

Antiprotozoal drugs

Amoebiasis can occur in any age even < 1year Diagnosis by stool analysis Amoebiasis...vegetative form or cystic form Anti amoebiasis 25-35 mg/kg/day in 3 divided doses paromomycin For 5-7 days
N.B

Gabbroral Susp 125mg/5ml Tab 250mg/tab

- Safe from first day of life - Active against cystic&vegetative form - No metallic taste - Safe in pregnancy&lactation 10 mg/kg/day in 3 divided doses For 7-10 days In susp form 2-5 yrars old5ml / tds 5-7 years old7.5 ml / tds > 7 years old10 ml / tds
N.B

Diloxanide

-not safe before 2 years - drug of choice against cystic form

Present in combination with Metronidazole: -Furazole -Dilozole -Dimetrole .Susp=100mg diloxanide +200mg Metronidazole .Tab=250mg diloxanide +200mg Metronidazole

Tinidazole Scinidazole

30-50 mg/kg/day single daily dose For 3 days

Protozol tab tab 500mg/tab N.B Fladazol -not safe before 3 days -very bad taste so Sachet &tab 500mg -common side effect nausea, headache Vommitting & anorexia

Metronidazole

35-50mg/kg/day in 3 divided doses Fore 7-10 days

N.B

1-safe from first day of life

2-active maily against vegetative form

3-main side effect metalic taste

[52]

Flagyl,Dumozol Entophar,Amrizol susp..125mg/5ml tab...250 ,500 mg/tab Flagellat forte susp 200mg

Other drugs

-Furazolidone -Chloroquine -iodoquinolone

N.B

These drugs are contraindicated in G6PD

Nitazoxanide

1-4 years old5ml/12h for 3 days 4-8 years old10ml/12h for 3 days Active against Giardia,Rota virus
N.B

Nitazode susp 100mg/5ml

Can be used in patients <2 years with H.nana

Conclusion
A-In cystic form< 2 years..Paromomycin or Metronidazole for one week then no ttt for one week then Metronidazole for another week > 2 year diloxanide metronidazole combination for 10 day B-In vegetative form metronidazole whatever age for 7 days

Giardiasis
-can also occur in any age -symptoms may be more severe than amoebiasis -suspect when there is fat globules in stool(fat malabsorption) Ttt:The same as amoebiasis But for 5-7 day

[53]

Diseases of git
A-Teething and its problems
Eruption of teeth may cause inflammatory changes&swelling of gum Symptomsirritability ,loss of appetite ,excessive salivation ,finger suckling - --- Signsoedema+erythema of gum eruption cyst may beseen erupting tooth(lower central incisors) may be seen N.B Many conditions are ascribed to teething such as diarrhea , rash, chesy troubles But any real correlation is doubtful TTT A -Local anaethetics(teething gel) e.g Oracure oral gel Dentocaine oral gel N.B -Dentocalm oral gel contain clove oil ( ) cause burning sensation Mouth -Over use of these topical anaethetic drugs my cause numbness &anaethesia Of entire pharynxinhibition of gag reflexserious aspiration occurs B-Systemic analgesics e.g Paracetamol Tempra ,Cetal Ibuprofen Brufen C-Teething toys for distraction purpose only i.e cause numbness in gum D-Massaging gum ??? Delayed teething Examine for other signs of rickets TTTprophylactic dose of vit D3 400 iu/day e.g Vidrops 4-10 drops /day
[54]

B-Gingivostomatitis
Infectious: A-viral: 1-herpetic stomatitis Aetiology HSV-thpe 1 clinically -abrupt onset of fever,oral pain,malaise -Salivation,Refusal of feeding -oral lesions appear 1-2day later vesiclesruptureulcer -2-10mm in size -covered e grayish membrane -on tongue , checks but can affect all Oral mucosa -submaxillary lymphadenopathy is common -dehydration is the main complication DD -herpangia...high fever,sore throat +vomiting,headache,abd. pain Oral lesionsdiscret ulcer Surrounded by red margin On pillar,tonsils,pharynx But not on cheecks or gum -chichen poxskin rash are characteristic -measleskopliks spots TTT ) ( 1-systemic analgesic antipyretics Paracetamol , brufen , declophenac 2-local anaethetics BBC spray (the best drug) Oracure oral gel Dentocaine oral gel Xylocaine viscus 5 Non infectious A-Eruptive stomatitissee above B-Aphthus ulcer -well circumscribed ulcer e white base &congested margin -In any area of oral cavity especially floorOf mouth,ventral surface of tongue But never over hard palate N.B--In recurrent aphthus ulcer search for: -vit deficiency -GERD -psychological trouble e.g TTT 1-Topical applications: - Solcoseryl oral paste 4-3 Or Mundisal oral gel 6-5 Or Jogel oral gel Or Kenalog in orabase (cotain triamcinolon 38 ) N.B--1 N.B2 Salivex paint -used in older childrens -cause severe pain on application 2-Systemic analgesics: -Paracetamol -Ibuprofen -Declophenac

[55]

3-in.severe cases Immunocompromised Neonates C-Traumatic ulcerhistory of trauma Systemic antiviral are used D-Local reactionchelitis due to Acyclovir dose10mg/kg/dose sensitivity 5 times /day for 5-10 days to contact substances in toys,food,pacifier preparationzovirax susp 400mg/5ml (100ml 47) E-Drugsphenytoin Novirus susp 200mg/5ml corrosives (125ml 33) 4-IV fluid e prolonged refusal of feeding F-Micronutrient deficiency B-Fungal Aetiologycandida albican clinicallynumerous small white flaks covering oropharyngeal mucosa & tongue if removed b tongue depressor Leave red haemorrhagic surface +salivation,pain,refusal of feeding DD 1-milk cruds on tongue: can be removed easily leaving normal surface under it 2-geographical tongue: Of no clinical signifigance TTT drops..(better than gel) Mycostatin .Fungiststin -1 dropper under tongue drop by drop Every 6 hours for 7 days Gel. Miconaz , Daktarin, Micoban(cotain local anaesthetic too) 7 6

[56]

C-Gastroesophogeal reflux disease

Two questions
1-It is Regurgitation or Vomiting ?
In regurgitation Not accompanied e nausea No forceful contraction of abd muscles In vommitting Associated e nausea There is forcible contraction of abd muscles

2-If Regurgitation it is Physiological or Pathological?

Physiologica
-Called posseting -Weight is not affected -Volume is small in amount 1-2 mouthfuls -Occur short time after feeding - Need no ttt

Pathological -Called GERD

-Weight is affected -Volume is large enough to soak clothes or sheet -Occur immediately or several hours after feeds -Need ttt

C/p of GERD:
1-Regurgitation 2-Failure to thrive (poor wt gain) 3-Aspiration of refluxed fluidnocturnal cough Recurrent aspiration pneumonia 4-Esophogitisirritability &crying in young infants or heart burn&dysphagia in olders

[57]

IX
1-Gatrographin swallow 2- US toexclude CHIPS 3-Esophagial ph monitoring!!!

TTT
1-Non pharmacological=instructions -Small feeds at more frequent intervals -Eructationend of feedingat middle & of feeding
-Positining 32 -Thickening formula 3-2 -Special formulanutrilon AR Babelac AR =antiregurge 2-Pharmacologlical ttt -Protokinitic drugs Gast-reg susp 1 cm/kg/day in 3doses 15 min before feeding -H2 blockers rantidine 5mg/kg/day (aciloc 75 mg/tab) -Proton pump inhibitors omeprazole ,5-1 mg/kg/day single daily dose -Antacid infant 5ml tds Children 10ml tds 3-surgical ttt -Persistant reguegitation (inspite of ttt)withfailure to thrive Chronic pulmonary comx Apenic spells

[58]

D-GASTROENTRITIS
Causative organism Viral Rota virus

=Diarrhea + Vomiting + Fever

Bacterial E.coli -Non pathogenic
Protozoal Entamoeba
hitolytica

1st dayfever,vomiting, intestinalSounds -Pathonenic nd 2 daysevere watery -Enteroinvasive diarrhea+congested throat -Enterotoxigenic 3rd daydiarrhea -Enteroadhesive 4th daysvere watery diarrhea again Other bacteria Other viruses Salmonella,shigela, Enterovirus,echovirus, Campylobacter Coxackievirus

Giardia lambilia

Stool Criteria

-Watery(may be confused as urine) -High frequency -No blood -no mucous -no tenasmus -usually no abd pain Low grade(38c)or high grade(40c)

Watery High frequency(but less than viral) Little mucous More blood Tensmus Abd pain on &off Moderate grade fever(38.5-40c)

Semisolid Less frequent More mucous

Little blood Severe tensmus Severe abd cramp

Fever

No fever

Stool analysis

Free i.e no pus cells no mucous

Pus cells+bood+mucous

Entamoeba Or giardia +mucos&blood

[59]

Treatment=

A-General TTT -O.R.S.....oral rehydration solution + Antiemtics +Antipyretics +Antispasmoidics B-Specific TTT

Fluid+Food+Drugs(++)

Viral
Only general ttt No need for antibiotic therapy

Bacterial

Protozoal

Antibiotics are indicated only in: See git drugs -patient in shock Antiprotozoal -severe toxaemia drug -parentral diarrhea(d.t infection outside git) -causitive organism(stool culture)is Salmonella,shigella,campylobacter Choice of antibiotics: -Smx-TMP1cm/kg/day in 2 doses -ceftriaxone50-75mg/kg/day single daily -cefotaxime100-150mg/kg/day in 2 dose -Ximacef8mg/kg/day every 12 h -Vancomycinlast drug to be used

[60]

O.R.S
-Awell balaced mixture of electrolyties &glucose(added to ensure maximal absorption of water&Na) -Used in ttt of all types of dehydration,potassium depletion,base deficit caused by diarrhea Preparations Hydrosafe..) ( Rehydrozinc.. Lowhydran low Na content(designed to ttt secretory diarrhea of v.cholera) N.B ready made O.R.Sbabysol bottle Dose10-20 ml/kg/day(Maximum 1 sachet /kg /day) < 10 kg weight..60-100 ml/ motion >10 kg weight..100-140ml /motion

i.e
22 222 -1

) (
-2 5 -

N.B

Home made O.R.S

+ + + ) ( Diarrhea&diet 1-antidiarrheal diet.. )( - + - - - - - - - - --- 2-diet that diarrhea -- - Sugary food&drinkscause osmotic diarrhea
[61]

Dehydration
Types of dehydration: -Isotonicnormal serum Na (135-153 Mequ/l) -Hypotonicserum sodium <135 mequ/l -Hypertonicserum sodium >153 mequ/l Degree of dehydration:

Management:
-Evaluation of degree of dehydration .Frequency of diarrhea.mild 4-6 times /day Moderate 6-10 times /day Severe > 10 tlmes /day .Amount of diarrhea .Presence of vomiting .Tears present or not .Tongue dry or not .Urine output ? .Conscious level

[62]

-Fluid therapy: a-Antishock therapy ...if the baby is shocked if not shocked but severe dehydration Amount 20ml/kg over 20 min 20 ml/kg over 1 hour Type ringers lactate or ringers lactate or Normal saline Normal saline b-Beficit therapy Amountmild dehydration..40 ml/kg moderate dehydration80 ml/kg severe dehydration..120 ml/kg Typein isotonic & hypotonic dehydration -glucose 5% + normal saline in ratio 1:1 +KCL 15% 1 ml/100ml of solution Or -kadlex + normal saline in ratio 1:1 contain K Duration over 8 hours in hyper tonic dehydration -glucose 5% + normal saline in ratio 4:1 +KCL 15% 1 ml/100ml of solution Or - kadlex + normal saline in ratio 4:1 contain K Duration over 24 hours c- maintenance fluid Amount 100 ml/ kg for first 10 kg of weight (wt 100) 50 ml / kg for second 10 kg of weight (1000+50[wt-10] if 10 >wt>20 ) 20 ml /kg for third 10 kg of weight (1500+20[wt-20] ) if wt > 20 ) Type -glucose 5% + normal saline in ratio 4:1 +KCL 15% 1 ml/100ml of solution Or -kadlex + normal saline in ratio 4:1 contain K Or -pansol Durationover 24 hour

[63]

During next 24 hour

If still dehydratred Repeat deficit&maintenance Therapy over 24 hours

if fully hydrated but there is severe diarrhea or vomiting The maintenance therapy + expected loss

if full hydrated&diarrhea is improving maintenance iv +1/2 maintenance oral in gradual manner

Calculation of rate of infusion:

= 3 =

[64]

Conistipation
Definition
Constipation is defined as two or fewer stools per week or passage of hard, pellet-like stools for at least 2 weeks .

N.B.1

Parents may have different descriptions about what is constipation. They may be referring to straining with defecation, a hard stool consistency, large stool size, decreased stool frequency, fear of passing stools, or any combination

I.e careful analysis of complaint

N.B2
Infants may experience symptoms of straining for prolonged periods and crying, followed by passage of soft stool. This pattern of difficult defecation is called infantile dyschezia and is present only in the first 3 months of life

I.e straining is normal till age of 3 months

In chronic constipation 2 or more of the following should be present
1- < 3 bowel movement / week 2- > 1 episode of encropresis / week 3- Impaction of rectum with stool 4- Rerentive posturing(standing or sitting with legs extended and stiff or
crossed legs) N.B3

Encropresis Involuntery leakage of fecal liquid from proximal colon around the
hard impacted stool in The dilated rectum leading to soiling of under wears

[65]

Causes of constipation

A-Functional
-Incidence90%of causes of conistipation in beyond neonatal period are functional

-Mechanisn & causes

Voluntary withholding of defecationwhy? 1-incorrect attempt in toilet training 2-intentional withholding as during Distention of rectum&colon school,traveling,family stress 3-emotional disturbances sensitivity of pressurereceptors in rectum 4-+ve family history defecation reflex&effectiveness of peristalsis Hard large stool in the rectum that is difficult&painful to evacuate Complications of constipationwhate are?

1-fecal impaction 2-anal fissure

3-abd pain 4-voiding dysfunctionstasisuti

5-encropresis
[66]

B-Organic
1-In neonates
-Anal stenosis -Imperforate anus---- usually discovered during rectal measurement of tempreture -Muconium plug -Hirschsprings disease----------------------Hirschsprung's disease results from the
failure of normal migration of ganglion cell precursors to their location in the gastrointestinal tract during gestation. The diagnosis can be made by obtaining an unprepped barium enema, which will demonstrate a change in the caliber of the large intestine at the site where normal bowel meets aganglionic bowel (transition zone). An unprepped barium enema is required because the use of cleansing enemas can dilate the abnormal portion of the colon and remove some of the distal impaction, thereby resulting in a false-negative result. After the study, the retention of barium for 24 or more hours is suggestive of Hirschsprung's disease or a significant motility disorder. Rectal suction biopsies or full-thickness surgical biopsies will confirm the absence of ganglion cells. Anal manometry is less reliable in children; in small infants, it requires specialized equipment.

-intestinal stricture
following necrotizing enterocliotis -hypothyrodism -Spinal Cord Defects

2-infant &children
-Obstructive lesions e.g intussuception , hirschsprings disease partial I .O e.g pyloric stenosis -Dietary causesinsuffecient intake of milk&fluid ,intake of diet low in vegetable fiber content - Painful anal&perianal conditionsanal fissure ,peianal dermatitis - Muscular hypotonia rickets , down $ , myopathies - Neurological causes cerebral palsy , spinal cord lesions -Endocrinal&etabolic hypothyrodism , hypokalaemia , hypercalcemia

hyperviyaminosis D
-Drugs antimotility(as antispasmoidics) , anticholinergics , opiates

N.B

. Extremely important. The presence of large amounts of stool in the rectal vault almost always indicates functional constipation. If no stool is present, Hirschsprung's disease and abnormal anorectal anatomy should be considered
[67]

How important is the rectal examination in patients with constipation?

Treatment:
1-TTT of causeinorganic type

2-Non pharmacological ttt -clearance of impacted fecal mass by enema (100 ml only) -regular post prandial toilet sitting ..in older infants -giving attention to any under lying psychological problems -dietary managementsee later 3-Pharmacological tttlaxatives 1-contact laxatives: -Glycrine infantil supp Used in acute constipation onlt for temporary relieve

Overuse cause laxative dependence

-Abilaxine, Bisadyl supp 2-osmotic laxatives -Magnisium hydroxide Dose 1teaspoon /10 kg once at night Preparations. Laxomag susp Very safe in pediatrics -Lactulose Dose 3 cm /kg at night or in divided doses Preparations.duphalac ,laxolac susp -Agiolax sachets..one sachet at night -Importal sachets no more avaible in market

Diet &constipation
-Before weaningwe can give water(after boiling) in between feds -From 3 months orange guice -From 4 months yugort 2 - --- ) ( - formula fortified e iron may cause conistipation

[68]

Abdominal pain
Causes of acute abdominal pain

[69]

Causes abdominal pain Causesof ofrecurrent recurrent abdominal pain

[70]

Cardiovascular system

You have to auscultate heart in every pediatric case once you hear any abnormal sound -----do Echocardiography
[71]

A-congenital heart diseases

Presentation of congenital heart defects

[72]

Here we will give short notes on most life threatening conditions which are ductal dependant lesions

Duct-dependant lesions
1-Duct- dependant cyanotic CHD
There is critical obstructive lesion of pulmonary blood flow E.G: 1-severe form of fallot tetralogy 2-traspositio of great arteries 3-tricuspid atresia 4-pulmonary atresia Clinically -----early onset canois,respiratory distrees&obstructive shock in severe cases

2-Duct- dependant non cyanotic CHD

There is critical obstructive lesion of systemic blood flowE.G: 1-critical aortic stenosis 2-critical coartication of aorta Clinically----poor peripheral perfusion,feeding difficulty,congestive heart failure&cardiogenic shock in severe cases I.X----doppler Echocardiography TTT 1-O2do not give 100% O2 2-prostaglandin E1 infusion: Mechanism:cause relaxation of smooth muscles of ductus Dose: ,05-2 mcg/kg/min Preparations: prostin vr amp 500 mcg/ml S.E: apnea so E.T should be considered 3-surgical correction of defect
[73]

B-Rheumtic fever
Autoimmune disease following upper respiratory tract infection with group A beta haemolytic streptococci 5-15 year is the peak but can occur in any age Diagnosis by modified JOhNS criteria: 1-two major manifestation OR one major +two minor manifestations 2-evidence of recent streptococcal infection MAJOR MAINFESTATIONS

1-Arthirits
Incidence: most common manifestation (75%) Character : 1-polyarticular-----affecting many joints 2-Transient-----affected joint resolve completely within one week 3-Migratory---- 4-Affecting large joints 5-The affected joint IS:swallen,red, hot&withmarke limitation of movement 6-Dramatic response to slicylate therapy Treatment: 1-Eradication of streptococci from throat 2-Salicylate: Dose--------80-100mg/kg/day in three divided doses after Meal for 3-4 weeks Preparation-------R0anal 500mg/tab ,Alexoprine 375mg/tab 3-Long acting penicillin :for 5 yearsor up to 20 years old which Far

[74]

2-CARDITIs:
Incidence: soet eresoae s siret tsom Character:1-disproportionate tachycardia I.E. increase heart rate by more than 10 beats for every degree rise in tempreture 2-newly heard murmer 3-pericardial rub I.X: color Doppler Treatment:1-eradication of strepotococci 2-carditis only: prednisolone 2mg/kg/day In 3 divided doses for 3 weeks Then gradual withdroal 3-carditis&arthiritis: prednisolone 2mg/kg/day In 3 divided doses for 2 weeks Then add salicylate 75-90mg/kg/day And strart gradual withdrual of prednisolone over 2 weeks And continue salicylate for 4-6 weeke 4-long acting pencillin: a-there is valvular lesion-------LAP for life b-no valvular lesion-----------LAP for 10 years or up to 25 years old which far

3-CHOREA:
Incidence: 10% of cases Character: involuntary movements Hypotonia Emotional disturbances Treatment:1- eradiction of streptococci 2-Halperidol(safinace)----,1-2,mg/kg/day Or Phenobarbital(sominalettta)---3mg/kg/day (Its better to refer the case to pediatric neurologist)
[75]

4-ERTHYMA MARGINATUM:
Incidence: 5% Character: serpigenous lesions Mainly on the trunk Increase in size with application of heat

5-SUBCOTANEUS NODULES:
Incidence:1% of cases Characters: painless nodules over bonny prominences

Minor manifestations
1-Fever-----ujually mild to moderate fever High fever should stimulate search for other cause 2-Arthralgia---should not considered as aminor one in Patients with arthritis 3-Abdominal pain 4-Epistaxis 5-Prolonged P-R interval-----should not considered as aminor one in patients with caritis 6-Acute phase reactant-----when they are +ve they are (the three)considered as one minorManifestation only

C.R.P
Normal--------<6mg% It increase----- in hours&decrease in hoursI.E. 4-3

E.S.R
normal------first hour 20 second hour 40 it increase ----in days&decrease in days

LEUOCYTOSIS
Normal-------4000-11000/cmm
[76]

Evidence of recent streptococcal infection

1-Antistrepotolysin o titer positive if titer more than 400 todds unit Rising titer N.B------ASOT.increase in weaks&decrease in weaks 2-Antihyaloronidase 3-Antistreptokinase 4-+ve throat culture 5-Recent scarlet fevr

2 major or 1 major+2 minor + Evidence of recent streptococcal infection

Common mistakes with rheumatic fever

1-Avoid diagnosis of rheumatic fever in: Age below 5 years Absence of major criteria In case of chronic arthritis or if arthritis Is monoarticular &non migratory 2-Do not accept history of previous R.F without documentation I.E: 3-Recurrent tonsillitis+high E.S.R or high A.S.O.T--------only means That this patient has streptococcal tonsillitis and not R.F 4-Avoid over diagnosis by accurate interpertion of clinical &laboratory data

[77]

Heart failure
Aetiology:
1-Contractility failure-------myocarditis,cardiomyopathy 2-After load failure--------acute glomerulonephritis,critical aortic Stenosis, critical coartication of aorta 3-Preload failure--------hypervolaemia E.G: acute renal failure,excess I.V fluids Big left to right shuntE.G: ASD,VSD,PDA 4-Arrhythmic failure-------severe tachycardia(paroxysmal supraventricular Tachycardia)

Clinically:
In right side hrart failure ----maifestations of systemic congestion 1-tachypnia 2-tachycardia 3-congested neck vein.difficult to be elicted in pediatrics due to short
neck
4-lower limb oedema..late sign 5-gallop rhythm

In left side heart failure---- maifestations of pulmonary congestion 1-cough,expectoration

2-DYSPNEA,ORTHOPNEA 3-RECURRENT CHEST INFECTION 4-BASAL CONSONATING LUNG CREPTITION IN COMPANSATING CASES---NO MAINFRSTATION OF LOW CARDIAC OUTPUT IN DECMPANSATED CASES---THERE IS MAINFESTATION OFLOW CARDIAC OUTPUT E.G: EASY FATIGBILITY LACK OF CONCENTRATION SNCOPAL ATTACKS OLIGURIA COLD PALE EXTREMITIES
[78]

I nvestigations:
1-Chest x ray---may show cardiomegally or pulmonary oedema 2-Ecg----arrhythmia,myocarditis,chamber enlargement 3-Echo----assessment of myocardial function,diagnosis of underlaying Cause 4-ABG

Treatment:
A-General-----1-O2 2-treatment of underlaying aetilogy if present 3-bed rest 4- salt restriction B-Specific-----according to type of H.F: 1-Preload failure.diuritics E.G: Lasix 1-2mg/kg/day every 6 hours Spironolactone 2-4mg/kg/day 2-Contractility.inotropic drugsE.G: Dopamine 10mcg/kg/min i.v drip in ICU Dobutamine 2-20mcg/kg/min i.v drip in ICU

Digoxin:
Dose-----,035mg/kg/day 8h 8h Digitalization dose=1/2 dose1/4 dose.1/4 dose Maintenance dose=1/4 dose once daily or in 2 divided doses Srart 24 H after intial digitalization dose Preparations------Lanoxin: Drops.,05mg/drop Tab.,25mg/tab ,05mg =1 ---- 5 Ampoules,5mg/2ml ,05mg =1 --- 12 3-after load failure---vasodilators E.g: Captopril1mg/kg

[79]

HEMATOLOGY

[80]

Hematology
How to read CBC ?
N.B WBC

CBC=complet blood coun CBC-D= complet blood coun with differential leukocytic count 4000-11000/cmm leukopenia<4000/cmm
causes...typhoid,BM depression eg aplastic anaemia

leukocytosis >11000/cmm causes.infection (bacterial or viral) to DD look at: Normal 25-30% (not more than 40%) At birth65% 2-4 years 45% >4 years 25% Monocytes 3-7% Oesinophils 1-3% Band cells 0% 1-neutrophil Neutrophilia=bacterial infection 2-lymphocytes Lyphocytosis=viral infection

Monocytosis : Brucella ,Typhoid TB , chronic infections Oesinophilia: Allergies e.g asthma Parasitic investation especially Visceral larva migrans If present =bacterial infection N.B.. -Bacterial infectionhigh leukocytosis +neutrophilia -Viral infectionmild to moderate leukocytosis +lymphocytosis Thrombocytopenia <150,000/cmm Thrombocytosis>400,000/cmm
[81]

Platelet

150000400000/cmm

Hemoglobin

12-16gm%

. What is the hemoglobin value below which children are considered to be anemic (lower limit of normal)? Newborn (full term) 13.0 gm/dL

3 months 1-3 years 4-8 years 8-12 years 12-16 years Blood indices 1-Mean corpuscular volume (M.C.V) =Haematocrite 100 RBC number 2-Mean corpuscular haemoglobin (M.C.H) = Haemoglobin RBC number 100 32-35 gm/dl

9.5 gm/dL 11.0 gm/dL 11.5 gm/dL 11.5 gm/dL 12.0 gm/dL

77-90 F.L (femto liter)

27-30 Pg (pico gram)

Used to DD B.W: Macrocytic anaemia >90 fl Normocytic anaenia 77-90 Microcytic anaemia <77 fl Used to DD B.W: Normochromic 27-30 pg Hypochromic<27 pg

3-Mean corpuscular haemoglobin Concentration (MCHC) = Haemoglobin 100 Haematocrite -Red cell distribution width(RDW) -Mentzer index = Mcv Rbc

13-16

-Up to 20 concides e iron deficiency anaemia - 21suspect thalassemia <13 iron deficiency anaemia >13 thalassemia

[82]

Anaemia
A-normocytic normochromic anaemia normal MCV &normal MCH
1-Hemolytic anaemia except thalassemia 2-Anaemin of acute blood loss 3- Anaemia with organs failure

B-microcytic hypochromic anaemia

1-Iron deficiency anaemia 2-Thalassemia 3-Sidroblastic anaemia 4-Anaemia d t lead poisoning

low MCV &low MCH

C-macrocytic anaemia
1-with vit B12 &Folic acidmegaloblastic anaemia 2-with normal vit B12 &Folic acidmylodysblastic anaemia Acquired sidroblastic Mylophthisic syndromes

high MCV

Iron deficiency anaemia

One of the most common types of anaemina world wide

Causes
1- Intake----diet deficient in iron..from dietetic history 2- Absorption---malabsorption $....undigested food particles in stool analysis or d.t constituents in diet that iron absorption ...from dietetic history 3- Loss----chronic blood loss e.g parasitic investation in stool analysis 4- Demand----during growth periods

[83]

c/p
1-General manifestations of anaemia -easy fatigue,palpitation,exertional dyspnea -Headache,dizziness,lack of concentration, Polyuria -pallor(in mucous membranes) -Hyperdynamic circulationtachycardia,bounding pulse, Haemic murmur 2-Specific manifestations of iron anaemia -nailsbrittle, flattened, loss of luster&spoonin -mouth.angular stomatitis,glossitis -neuro-psychiatric.picca(perverted appetite)e.g - +spleenomegaly 3-Maifestation of cause

IX
1-CBChypochromic microcytic anaemia

-haemoglobin <12gm/dl &haematocrite -MCV < 77 fl &MCH < 27 pg - number of RBC 2-Biochemicmainly to DD b.w ironanaemia &thalassemia -serum iron(n=70-140mcg%) -serum ferritin(n=1-30mcg%) -trasferrin saturation(n=30%) -TIBC(n=250-400mcg%)

-The ferritin level, is exquisitely sensitive to inflammation, increasing even with

mild upper respiratory infections. Elevations of ferritin may persist for some time. By contrast, serum iron transferrin level, and percent transferrin saturation may decrease with infection or inflammation 3-Stool examinationparasits ,occult blood or malabsorption

[84]

Ttt
1-TTT of cause: -parasitic investation.....see git drugs
-correction of dietary faults:

N.B

-Dietary iron
Non heme iron
-has to be reduced to ferrous state Before absorption

Heme iron
-easily digested & rapidly absorped -absorption is not affected by other costiteunts in diet -found in foods of animal origin.

-absorption is affected by other costiteunts in diet

-found mainly in

1,5-6mg/100gm of diet

---- ---)( + --- -----

Absorption by vit C e.g Civilline drops , Vitacid c eff tab absorptionby tannat i.e phosphate&phytate e.g cow milk,egg yolk,bread

Iron preparations

Dropsfer-in-sol drops SyrupK-G-ron(15mg iron/5ml) &Ferromix(15mg iron/5ml) Sytron(28mg iron/5ml) & Vitaferrol(38mg iron/5ml) Feose(50mg iron/5ml) Tablet theragran haematinic(66mg/tab) & ferose F (100mg/tab)

TTT for how long ? For 3-4 months

[85]

Hemolytic anaemia
Aetiology :
corpuscular

-Membrane defect e.g spherocytosis IXperipheral blood smear spheroctes +ve osmotic fragility test

-HB defect e.g thalasemia sicle cell anaemia

-Enzyme defect e.g G6pd pyruvate kinase

Glucose 6 phosphate dehydrogenase deficiency (G6pd )

Aetiology &genetics
Hereditary x linked recessive genetic of G6pd enzyme Sex . Fully expressed in hemizygous male &homozygous females But can occur in heterozygous females Age at any age

Pathogenesis
-G6pd enzyme is responsible for production of reduced NADPH &renewal of Reduced GLUTATHIONE(GSH) which protect RBC from oxidants by reducig them -so G6pd deficiency NADPH GSH protection of RBC from oxidants -so exposure of G6PD deficient RBC to an oxidantoxidation of haemoglobin -oxidized H.B is denaturated &deposetd as Heinz inclusion bodies on RBC -membrane integrity of RBC haemolysis

[86]

c/p
Diet..fava beans Drugs.antipyreticsall except paracetamol&mefenamic acid Sulphonamides Nitrofurans Antimalarials Antibiotics.chloramphenicol,nalidixic acid Diseases,viral URTI , DKA -Maifestation of acute haemolysis Acute pallor Dark or cola colored urine Jaundice -Nausea , vomiting, abdominal pain -Spleenomegaly in recurrent cases

-History of exposure to triggering agent

IX
-CBC with reticulocytic count. HB ,normal MCV & MCH (N N anaemia) of reticulocytic count - of G6PD level in RBC < 20 unit/10 RBC - serum bilirubin N.B---SGPT&SGOT to exclude hepatitis

ttt
1-avoid exposure of triggering agent
2-packed RBC transfusion= defeciet body weight 3 (normal HB=12g%)

[87]

Sickle cell anaemia

Chronic haemolotic anaemia d.t hereditary disorder in which abnormal Hb is presentHbS[2,2] Abnormal structure of chain of Hb valine replace glutamic acid in the 6th position of chain

pathophysiolgy
Abnormal HB when exposed to hypoxia Polymerize and forms insoluble aggregate RBCs become distorted and takes acharactristic sickle shape Rigid non compressiple cells c deformobility Obstruction of small blood vessels haemolysis [cell destruction]

[88]

c/p
-General manifestation of haemolytic anaemia -Episodic crisis of 4 types: Vasoocclusive (thrombotic or pinful) crisis D.Tocclusion of small bl-vsdistal ischaemia&infraction Clinicallyaccording to site of occlusion: -ishemic pain in hand&foot(hand&foot $ or dactylitis) -acute abdomin -cerebral stroke&neurological sequellae -renal infarction&papillary necrosishematuria -acute chest $ -priapism -splenic ifarctionautosplenectomy -svere back pain -pain in long boneavascular necrosis of joints TTT 1-adequqte hydration by IV fluids 2-analgesicsParacetamol or paracetamol+codeine(pyraphol supp) Ibuprofen 10-15 mg/kg/dose Morphine 0.1-0.2 mg/kg IV q4h; not to exceed 15 mg
Methadone .7mg/kg/day po/sc/im divided every 6-8h not to exceed10mg/dose Nalpuphine(nuban) not in young infancy 3-02 inhalation 4-antibioticsCefruxime(zinnat) 50-100mg/kg/day every 12 hour

Ceftriaxone (cefaxone) 50-75g/kg/day every 24 hour 5-prolonged severe painful crisispacked RBC transfusion Partial exchange transfusion

[89]

N.B
1-painful crisis affecting long bone.Do x ray to exclude osteomlitis AB is very important 2-in cerebral strokenever to give blood 3-in periapismsustained unwanted painful erection if prolonged more than 2hour Interfere by: aspiration of blood Intracorporal injection of adrenalin Irrigation by cold saline spleic sequestration crisis D.Tsudden pooling of large amount of blood in spleen&liver clinicallyrapidlly enlarged abdomen massive splenomegaly sudden circulatory collapse TTT - ttt of hopovolaemic shock -packed RBC transfusion to raise HB to 10gm% only if HB < 7gm% Aplastic crisis D.T sudden attack of transient bone marrow failure usually following infection Clinically-sudden onset of severe anaemia . Hemoglobin may fall as much as 10-15% per day without reticulocytosis -last for 10-14 day -CBC..anaemia or pancytopenia with normal or low reticulocytic count TTTimmediate blood transfusion to raise HB up to 10 gm% hyperhemolytic crisis uncommon , acute haemolytic crisis with jaundice , pallor, dark urine

[90]

Thalassemia
- Normal HB is made up of 4 polypeptide chain 2 & 2 non - Synthesis of globin chain is controlled by 4 genes ,while chains Is controlled by 2 genes HB Polypeptide chain % at birth % at 6 months 1-fetal HB(HBf) 2-adult 1 HB (HBA1 ) 3-adult 2 HB (HBA2) 2 +2gamma 2 +2 2 +2 delta 65% 34% < 1% 2% 95% 3%

Genetics&pathogenesis :

-in thalassemia there is impaired production of beta globin chain due to Deletion of one or both genes controlling its production i.e there is decreased Production of chains with normal production of chain this result In relative excess of chain which precipitate in RBC as inclusion bodies rigidity & destruction of RBC -in talassemia there is impaired production of globin chain due to Deletion of one or more genes responsible of its production

Types of thalassemia
1-

thalassemia :

Genetic deletion can affect one or more genes controlling chain synyhesis Deletion of 4 geneshydrop fetalis Deletion of 3 geneshaemoglobin H disease(c/p as thalassemia major) Deletion of 2 genes.. thalassemia trait(c/p as thalassemia minor) Deletion of 4 genessileny carrier

[91]

2- thalassemia:

1-Minor type heterogenous thalassemia HB A1 is predominant,HB A2 > 4% , HB f may slightly Anaemia is mild.9-11gm% 2-Intermediate type Affect 2% of homozygous patients Patient has higher ability to produce chain(more than in major type) Genetics,morphology,biochemical features like thalassemia major Blood transfusion not needed routinely 3-Major type Homozygous thalassemia HB f predominas Blood transfusion needed routinely

Clinical features
1-general manifestation of anaemiasee iron defeciecy anaemia 2-general maifrstations of haemolysisjaundice,dark stool.dark urine 3-maifrstations of medullary erythropoiesisthalassemic facies thalassemic facies enlarged head, frontal&parietal bossing protruded maxilla, depressed nasal bridge slantig of eye&epicathic folds 4-maifrstations of extramedullary erythropoiesis hepatomegaly &spleenomegaly lymphadenopathy 5-growth retardation 6-mainfestations of complications Haemosidrosis 2ry hyersplenism Comx of blood transfusion

[92]

Investigations
1-CBCmicricytic hypochromic anaemia(HB, MCV, MCH) reticulocytic count Lymphocytosis & leukocytosis usually present RDW Mentzer index Target cells, anisocytosis 2-Biochemical studies Serum iron, Serum ferirtin HB electropheresis..need skilled technician HB f = thalassemia major N.B HB A2 = thalassemia minor HPLC = high performance chromatography A more accurate substitute for HB electropheresis in diagnosis thalassemia

Treatment
1-Packed RBC transfusion: According to the following equationdefeciet body weight 3
Every 3 cm packed RBC HB 1gm/kg Consider normal HB =12 gm/dl 2-Iron chelating agents a-arentraldesferoxamine dose----30-40mg/kg/day s.c, im, iv

or iv infusion in a rate 12-15mg/kg/h over 12 hours

b-Oraldeferasirox(Exjade) dose---20mg/kg/day oral on empty stomach

or 30 min before meal ----calculate dose to the nearest whole tablet Dissolve tablet in water or juice &drink immediately ---- maintenance dose.5-10mg/kg/day ----adjust dose every 3-6 months not to exceed 30mg/kg/day

[93]

N.B

Diet: Drinking tea with meals reduces dietary iron absorption 3- folic acid1-5mg/day 4-antibioticerythromycin or long acting pencillin /3 weeks 5-vaccination.pueumococci,meningococci,haemophilus influenza 6-lasix 1mg/kg/dose following blood transfusion(to avoid volume over load) 7-CST 8-bone marrow transplantation.is the only radical treatment

Bleeding disorders
Evaluation of a child with bleeding or abnormal coagulation screening tests

[94]

Bleeding time prolongedplatelet or vascular disorder Coagulation time prolonged Coagulation factor defect

Haemophilia
Types
1-haemophilia A factor 8 most common 2- haemophilia B factor 9 3- haemophilia C factor 11

C/p
joint

------------------- bleeding tendency : -prolonged bleeding after minor trauma,circumcision or spontaneous -hemoarthrosislimping & pseudoparalysis my be recurrent leading to Ankylosis of -Ecchymosis -Haematuria -M M bleeding -dangerous sitesintrscranial,intraocular,retroperitoneal haemorrhage

Ix Ttt

-BT , PT normal -PTT prolonged -factor 8 assay 1-prevent bleeding.avoid IM injections ,violent excercises,aspirin 2-local measures to arrest bleeding.presure, cold compresses, immobilization 3-replacement therapy. Preparations ..Fresh frozen plasmaevery 1ml contain 1 unit of factor 8 cryoprecipitateeach bag cotain 125 unit of factor 8 factor 8 concentrate250 or 500 unit/ vial Dose..25 unit/kg/12h. for usual hemarthrosis 25-50unit/kg/12h.for GIT or hematuria
50-75unit/kg/8h.for CNS bleeding

4-antibioticespecially antistaph especially in haemoarthrosis

[95]

CNS

[96]

CNS
Convulsion
Definition:
Seizure is a sudden, transient disturbance of brain function, manifested by involuntary motor, sensory, autonomic, or psychic phenomena, alone or in any combination, often accompanied by alteration or loss of consciousness. Seizures can be caused by any factor that disturbs brain function. They may occur after a metabolic, traumatic, anoxic, or infectious insult to the brain (classified as remote symptomatic seizures), or spontaneously without prior known CNS insult. Repeated seizures without evident acute symptomatic cause (eg, fever) are defined as epilepsy. Causes of convulsions

[97]

Causes: 1 Acute symptomatic or provoked: With fever: 1 Febrile seizures due to infections outside CNS. 2 Intracranial infection meningitis, encephalitis, brain abscess, subdural or extradural. Abscess, septic venous thrombosis Without fever: 1 Traumatic: -brain concusion ,contusion , intracranial haemorrhage. 2 Toxic: -exogenoustetanus, shigellosis, aminophylline , antihistaminics lead. -endogenousuremia , hepatic failure , DKA 3 Hypoxic: -cardiac arrest , near drowning , acute vascular collapse 4 Metabolic: -hypoglycemia, hypocalcemia, hypomagnesemia, hypo&hypernatremia 5 Vascular: -hypertensive encephalopathy, cerebral strokes 2 Epilepsy (chronic or recurrent unprovoked convulsion) see the definition

[98]

Febrile convulsion
Cause rapid rise of body tempreture due to infections outside CNS Criteria 5 criteria must be present (all of them) for diagnosis: 1 age..6 months till 5 years old 2 fever...rapid rise of body tempreture , 3 convulsion: onset within 8-12 hour of onset of fever type generalized tonic clonic i.e. ( ) Duration less than 15 min Postictal stupor is short Frequency one fit during same illness 4 normal neurological evaluation 5 evidence of extracranial infectionmost common causes are o.m , tonsillitis , UTI , G.E N.B EEG are not routinely recommended except: 1- +ve family history of epilepsy 2- previous neurological illness 3- atypical presentation() e.g nofever ,prolonged ,focal EEG if indicated, it should be made only after at least 2 week from last fit ttta if during fit of convulsion: 1-emergency rescutationA B C 2-termination of attack of convulsionneural ,3mg/kg IV or ,5mg/kg rectal 3- + as below b if after attack of convulsion: 1-lowering body tempreture..tepid sponging + antipyretics(e.g cetal supp) 2-ttt of cause of fever..e.g antibiotic for O.M 3-exclusion of intracranial infection Prolonged anticonvulsant prophylaxis for preventing recurrent febrile convulsions is controversial and no longer recommended for most children If parental anxiety is very high, oral diazepam may be used as an effective and safe method of reducing the risk of recurrence of febrile seizures. At the onset of each febrile

[99]

illness, oral diazepam, 0.3 mg/kg q8h (1 mg/kg/24 hr), is administered for the duration of the illness (usually 23 days).

CNS INFECTIONS
1Encephalitis:
Causes viral infection..enterovirus , varicella ,EBV or herpes allergic reaction following infectionpost infectious demylinating encephalitis e.g mumps allergic reaction following vaccination..pertussis ,influenza N.B---mycoplasma encephalitis usually preceeded by lobar pneumonia Clinically history of preceeding viral infection( e.g URTI) , vaccination or mycoplasma pneumonia fever followed by drowsiness , bizzar behaviour or deep coma(early) convulsion &intracranial pressure(late in encephalitis early e meningioencephalitis) I.X. CSF findingssee meningitis CT&MRI.may show swelling of brain parenchyma EEG TTT supportivethis the main ttt .antipyretics , control of convulsion , rest , iv fluids antibioticsalthough mostly viral broad spectrum AB must be given until CSF results ceftriaxone OR ceftazidime 100mg/kg/day OR cefotaxime OR cefoperazone 200mg/kg/day +ampicillin 300mglkg/day In herpitic encephalitisacyclovir 10mg/kg/dose IV over1hour every 8h e.g zovirax vial 250mg/5ml

[100]

2MENINGITIS:
Causes neonatesgrm-ve enteric flora(e.coli) , group B streptococci ,listeria , staphylococcus infancyHemophilus influenza type B , pneumococcus , meningococcus older children meningococci is more common other organisms include.pseudomonas , proteus , klebsiella Clinically onsetmay be rapid (as with meningococci& pneumococc) or subacute(with H.influenza) signs of meningeal irritation: In small infant.irritability , restleeness , poor feeding In older children..photophopia , headache , irritability 1- neck stiffness. Grades of neck stiffness.guarding ,rigidity ,hyperextension 2-back signs..back pain, tripod sign(sit unsupported on the buttocks&ul),opisthotonos 3-kernigs signinability to extend the knee with hip flexed 4-brudzinski sign..head flextionleg flextion(head to leg sign) Flextion of one leg Flextion of the other leg(leg to leg) signs&symptoms of intracranial pressure: In small infantbulging anterior fontanel ,cracked pot percussion note over the skull In older children..headache ,projectile vomiting , blurring of vision,photophopia In any ageirregular respiration , blood pressure , slow pulse other findings: Fever (may be abscent) Changes in sensorium vary from mild lethargy to coma Convulsions(common &early) Focal neurological signs Purpuric rash =meningococcemia

[101]

I.X. 1-lumbar pucture

Cerebrospinal Fluid Findings in Various Central Nervous System Disorders Protein Glucose Condition Pressure Leukocytes (/L) (mg/dL) (mg/dL) Normal 50-180 mm <4; 60-70% 20-45 >50 or 75% H2O lymphocytes, 30blood glucose 40% monocytes, 13% neutrophils Acute bacterial Usually 100-60,000+; 100-500 Depressed meningitis elevated usually a few compared with thousand; PMNs blood glucose; predominate usually <40 Partially treated Normal or 1-10,000; PMNs >100 Depressed or bacterial meningitis elevated usual but normal mononuclear cells may predominate if pretreated for extended period Tuberculous meningitis Usually elevated; may be low because of CSF block in advanced stages Usually elevated 10-500; PMNs early but lymphocytes and monocytes predominate later Comments

Organism may be seen on Gram stain and recovered by culture

Organisms may be seen; pretreatment may render CSF sterile in pneumococcal and meningococcal disease, but antigen may be detected 100-500; <50 usual; Acid-fast organisms may be decreases with may be seen on smear; higher in time if organism can be presence of treatment not recovered in culture or CSF block provided by PCR; PPD, chest xray positive <50; decreases with time if treatment not provided Budding yeast may be seen; organism may be recovered in culture; India ink preparation or antigen may be positive in cryptococcal disease Generally Enteroviruses may be normal; may recovered from CSF be depressed to by appropriate viral 40 in some cultures or PCR; HSV viral diseases by PCR (15-20% of mumps) Normal Profile may be completely normal

Fungal

25-500; PMNs 20-500 early; mononuclear cells predominate later

Viral meningitis or Normal or meningoencephalitis slightly elevated

PMNs early; 20-100 mononuclear cells predominate later; rarely more than 1000 cells except in eastern equine 0-100 PMNs 20-200 unless rupture into CSF

Abscess (parameningeal infection)

Normal or elevated

[102]

HSV, herpes simplex virus; PCR, polymerase chain reaction; PMNs, polymorphonuclear leukocytes; PPD, purified protein derivative of tuberculin.

2-CBC 3-blood culture 4-CT in presence of focal signs TTT 1 - supportive. antipyretics , control of convulsion , rest , iv fluids 2 - ANTIBIOTICSemprical(baed on common etiologist) ceftriaxone OR ceftazidime 100mg/kg/day OR cefotaxime OR cefoperazone 200mg/kg/day + ampicillin 300mglkg/day OR Unictam OR augmentin N.Bchloramphenicol 100mg/kg/day in patients sensitive to cephalosporines Adjust the ttt regimen according to results of culture Duration of ttt 10-14 day in neoborn 3weeks CSF must become normal &sterile -Use of CST.. Use of dexamethasone for ashort period early in the disease(under good cover of AB) May reduce the incidence of neurological complications Dose at 0.15 mg/kg q6h for 2-4 days.

Short notes on epilepsy

- Epilepsy is considered to be present when 2 or more unprovoked seizures occur At an interval greater htan 24 hours apart -Epilepsy is classified A) Partial seizures: 1) Simple partial Motor, sensory , autonomic , psychic 2) Complex partial Simple partial, followed by impaired consciousness. Consciousness impaired at onset. 3) Partial seizures with secondary generalization. b) Generalized seizures
[103]

1) Absences: - Typical , Atypical. 2) Generalized tonic clonic. 3) Tonic. 4) Clonic. 5) Myoclonic. 6) Atonic. 7) Infantile spasms. C) Unclassified seizures.

Treatment of epilepsy:
1-General measurementparentral worries about prognosis ,present &future life style, education , marriage ,pregnancy should be discussed and clarified 2-During attack of convulsion a-first aid(emergency resuscitation) should be done in every case regardless of seizure Duration and should be taught to parents so they can do it at home: -put in left lateral position -extend the neck / elevate the jaw -remove tight clothes/donot restrain -nothing per mouth (even tongue depressor) -no mouth to mouth breathing b-suction&cleaningan oropharyngeal air way may be needed c-give 02 if patient is cyanosed or convulsing >2min d-emergency drugsthe drug of choice diazepam .3mg/kg/dose(10mg/2ml) slowly IV can be repeated after 10 min if convulsion stop during injection stop injection if no venous access the same dose can be given rectally by insulin syring(without needle) 3-Long term therapy: -When to start?anti-epiletic drug is started usually after 2nd afebrile attack Ques -Should treatment with antiepileptic drugs be started after the first seizure in a child? Answer-"Delaying" treatment until after the second seizure does not adversely affect the long-term chance of epilepsy remission

[104]

-How to start?perferlably use one drug only(monotherapy) on the lowest dose that control condition if polytherapy ensure that used drugs are compatible with each other -Which drug ? -Phenobarbital Dose..3-8mg/kg/day Preparationsominaletta syrup 15mg/5ml Tablet 15mg/tab Amp 40mg/ml - Pheytoin Dose...10-15mg/kg/day Preparation.epanutin amp 250mg/5ml Epanutin susp 30mg/5ml -Carbamazepine Dose.10-20mg/kg/day Preparationstegretol susp 100mg/5ml & tab 200mg/tab Tegretol CR 200&400mg/cap -valproic acid Dose20-30mg/kg/day Preparation convulex drops 300mg/ml (10mg/drop) &cap 150-300m/cap Depakine syrup 200mg/5ml &tab 200mg -clonazepam dose. ,05-,1mg/kg/day preparation.rivortil- apetryl-amotryl tablet ,5mg&2mg/tab Rivortil drops ,1mg/drop In generalized epilepsy..valproate &cabamazepine In petit mal epilepsy...clonazepam&valproate -How much and how often? 1-the smallest dose to keep the child fit free 2-give the drug in two or three doses per day -For how long?ttt lasts until the patient is seizure free for 2 years then the drug is withdrawn Very gradually over 3 months -Restriction generally no restrictions in food ,sports,beverage

[105]

Common Anticonvulsant Drugs(NTP 18) SEIZURE TYPE LOADING DOSE (IV) THERAPEUTIC SIDE EFFECTS SERUM LEVEL AND (G/ML) TOXICITY 812 Dizziness, drowsiness, diplopia, liver dysfunction, anemia, neutropenia, SIADH, blood dyscrasias rare, hepatotoxic effects Dizziness, fatigue, weight gain, ataxia and behavior problems Drowiness, irritability, agitation, behavioral abnormalities, depression, excessive salivation

DRUG

ORAL DOSE Begin 10 mg/kg/24 hr Increase to 20 30 mg/kg/24 hr tid

Carbamazepine Generalized (Tegretol) tonic-clonic Partial

Clobazam (Frisium)

Adjunctive therapy when seizures poorly controlled Absence

0.251 mg/kg/24 hr bid or tid

Clonazepam (Rivotril)

Children <30 kg: Begin 0.05 mg/kg/24 hr Increase by 0.05 mg/kg/wk Maximum 0.2 mg/kg/24 hr bid or tid Children >30 kg: 1.5 mg/kg/24 hr tid, not to exceed 20 mg/24 hr

>0.013

Myoclonic Infantile spasms

Partial

Lennox-Gastaut Akinetic Ethosuximide (Zarontin) Absence May increase tonic-clonic seizures Begin 20 mg/kg/24 hr Increase to maximum of 40 mg/kg/24 hr or 1.5 g/24 hr, whichever is less Children: 2050 mg/kg/24 hr tid [106] Not necessary to monitor 40100 Abdominal discomfort, skin rash, liver dysfunction, leukopenia

Gabapentin (Neurontin)

Adjuntive therapy when

Somnolence, dizziness, ataxia,

DRUG

SEIZURE TYPE seizures poorly controlled

ORAL DOSE Adolescence: 9003,600 mg/24 hr tid

LOADING DOSE (IV)

THERAPEUTIC SIDE EFFECTS SERUM LEVEL AND (G/ML) TOXICITY headache, tremor, vomiting, nystagmus, fatigue and weight gain Rash, dizziness, ataxia, somolence, diplopia, headache, nausea, vomiting

Lamotrigine (Lamictal)

Adjunctive therapy when seizures poorly controlled Broad-spectrum anticonvulsant activity in various seizure types including: complex partial, absence, myoclonic, clonic, tonicclonic, and Lennox-Gastaut

Individualized based on age and additional anticonvulsants (see Chapter 593.6 )

Nitrazepam (Mogadon)

Absence Myoclonic Infantile spasms

Begin 0.2 mg/kg/24 hr Increase slowly to 1 mg/kg/24 hr tid

Similar to clonazepam, hallucinations

Paraldehyde

Generalized Make a 5% status epilepticus solution by adding 1.75 mL of paraldehyde to D5W with total volume of 35 mL Generalized tonic-clonic Partial Status epilepticus

150200 mg/kg Maintenance, 20 mg/kg/hr

1040

Phenobarbital

35 mg/kg/24 hr 20 mg/kg bid 2030 mg/kg in the neonate

1540

Hyperactivity, irritability, short attention span, temper tantrums, altered sleep pattern, StevensJohnson syndrome, depression of

[107]

DRUG

SEIZURE TYPE

ORAL DOSE

LOADING DOSE (IV)

THERAPEUTIC SIDE EFFECTS SERUM LEVEL AND (G/ML) TOXICITY cognitive function

Phenytoin (Dilantin)

Generalized tonic-clonic Partial Status epilepticus

39 mg/kg/24 hr 20 mg/kg bid

1020

Hirsutism, gum hypertrophy, ataxia, skin rash, Stevens-Johnson sydrome, nystagmus, nausea, vomiting, drowsiness, coarsening facial features, blood dyscrasias Aggressive behavior, personality changes, similar to phenobarbital

Primidone (Mysoline)

Generalized tonic-clonic Partial

Children <8 yr: 1025 mg/kg/24 hr tid or qid Children >8 yr: usual maintenance dose, 7501,500 mg/24 hr tid or qid

512

Topiramate (Topimax)

Adjunctive 19 mg/kg/24 hr therapy for bid poorly controlled seizures Refractory complex partial seizures

Fatigue, cognitive depression

Tiagabine (Gabitril)

Adjunctive therapy for complex partial seizures Generalized tonic-clonic Absence Myoclonic

Average dose, 6 mg tid

Asthenia, dizziness, poor attention span, nervousness, tremor Nausea, vomiting, anorexia, amenorrhea, sedation, tremor,

Valproic acid (Depakene, Epival)

Intravenous 50100 preparation Increase by 510 now available Studies in mg/kg/wk children under Usual dose, 30 Begin 10 mg/kg/24 hr [108]

DRUG

SEIZURE TYPE

ORAL DOSE 60 mg/kg/24 hr tid or qid

LOADING DOSE (IV) way

THERAPEUTIC SIDE EFFECTS SERUM LEVEL AND (G/ML) TOXICITY weight gain, alopecia, hepatotoxicity

Partial Akinetic Vigabatrin (Sabril) Infantile spasms Begin 30 mg/kg/24 hr once daily or bid

Hyperactivity, agitation, excitement, somnolence, weight gain Note: Reports of visual field constriction, optic pallor or atrophy, and optic neuritis

Adjunctive therapy for poorly controlled seizures

Maintenance dose, 30100 mg/kg/24 hr once daily or bid

SIADH, syndrome of inappropriate secretion of antidiuretic hormone.

[109]

Should an EEG be done on all children who have a first afebrile seizure?

This is a major controversial issue. Of new-onset seizures in children, about one third do not involve fever. The American Academy of Neurology has recommended that all children with a first seizure without fever undergo an EEG in an effort to better classify the epilepsy syndrome. Others argue that the quantity of expected information from obtaining EEGs for all cases is too low to affect treatment recommendations in most patients. They suggest that a selective approach to EEG use should be pursued, particularly for children with a seizure of focal onset, for children <1 year old, and for any child with unexplained cognitive or motor dysfunction or abnormalities on neurologic examination. Should all children with a new-onset afebrile generalized seizure have a CT or MRI evaluation? Although most adults with new-onset seizures should have a head imaging study (preferably MRI), the relatively high frequency of idiopathic seizure disorders in children often obviates a scan in those with generalized seizures, nonfocal EEGs, and normal neurologic examinations. Consider obtaining a cranial imaging study in the following situations:

Any seizure with focal components (other than mere eye deviation) Newborns and young infants with seizures Status epilepticus at any age Focal slowing or focal paroxysmal activity on EEG

[110]

GULLIAN-BARRE SYNDROME
Icidencemost common cause of acute paralysis in pediatric age group Cause It usually follow viral infection (hence the name post infectious poly neuritis) sensitized lymphocytes cause demylination of the peripheral nerves mainly at junction of anterior & posterior nerve roots(spinal nerves). The damage is mainly motor Clinically 1- motor manifestations(predominat):bilateral symmetrical weakness begins usually in the lower limb &progress to involve the trunk ,upper limbs & finally the bulbar musclesRepiratory paralysis(ascending paralysis e bilateral total distal areflexia) 2- sensory mainfestationtender muscles &paraethesia in some cases 3- autonomic maifestation in some cases urinary incontinence or retention , postural hypotension I.X. 1-CSF..protein cell dissociation(protein ,normal cell) 2-nerve conduction pattern..decreased 3-EMG.denervation pattern 4-serum CPK.normal TTT 1- supportive.in acute phase the patient must be hospitalized as patient may need mechanical Ventilation 2- specific . One of following ttts OR both a-IV immunoglobulin 0.4 g/kg/d IV for 5 d b-plasma exchange five exchanges of 50mg/kg/day over 7-10 days 3-physiotherapy.to restore normal function

[111]

Status epilepticus
It isastate of continuous epileptic activity(clinical& / or EEG)for 30 min or more and/or serial attacks without return of consciousness in between for 30 min or more Management better in ICU . steps: ABCDE A- airwayestablish apatent oral airway by suction,semiprone oosition+ put oropharyngeal airway tube B- breathing 1-give 100% o2 by mask , or ambu bag 2-If needed assisted ventilation 3-Intiatevpulse oximetry to maintain o2 saturation C-circulation 1-asses pulse , BL.P ,rectal tempreture 2-insert IV line . draw blood samples for blood glucose,electrolytes,bicarbonate level CBC , anticonvulsant drug level(if on ttt) 3-start drip of glucose 10% as 2ml/kg , shock therapy if shocked Then IV fluids giving 2/3 of daily maintenance requirements 4-ABG measurement D-DRUGS Stage 1 0-5 min no drugs Stage 26-16 min First line drugs: a benzodiazepine a- Diazepam(neural 10mg/2ml) ,3mg/kg/dose slowly IV ,5 mg/kg/dose rectally by insulin syring(without needle) Can be repeated after 5 min b- LorazepamLorazepam, when available, is thought to be the most
effective and has a longer seizure half-life than diazepam. Dose infants and children: 0.1 mg/kg IV slowly over 2-5 min; repeat prn in 10-15 min at 0.05 mg/kg; not to exceed 4 mg/dose
[112]

c- Midazolam Loading dose: 0.15 mg/kg IV Maintenance dose: 1 mcg/kg/min; titrate dose upward q5min until clinical seizure activity controlled

Stage 316-35 min second line drugs phenytoin sodium or fosphenytoin -Phenytoin.
Loading dose: 18-20 mg/kg IV; hypotension may necessitate slowing administration rate; rate not to exceed 50 mg/min (hypotension and arrhythmias can otherwise occur); if status epilepticus persists, may increase to total of 30 mg/kg -Barbiturates15-20 mg/kg over 10-15 min IV in single or divided dose

-Midazolam
N.B

After intial control of convulsions. A maintenance dose of Phenobarbital(2-3mg/kg/dose iv /8-12h) + phenytoin(2-3mg/kg/dose iv /8-12h) May be needed for 1-2 days to prevent recurrence

Stage 4 >35 min Midazolam: ,1mg/kg/hour (1 ml dormicum+100 saline infusion at arare of 2ml/kg/h) Pancuronium :,1mg/kg IV entubation then mechanical ventilation Thiopental: 2-4mg/kg IV followed by constant infusion 2mg/kg/hour for 48 hour

[113]

Renal System

[114]

Urinary system
Urine analysis
How to obtain urine sample in pediatric?
1-mid sream clean catch..in older children wirh urinary Control i.e. i.e.who can Void on request 2-sterile urine bag...in infants&young children who can not void on request 3-catheter 4-subrapubic aspiration the ideal way to obtain sample sterile bag N.B

A-Physical properties
1-aspect 2-colour Clear Amber yellow

Comment Turbid----contaminated container, pyuria,crystaluria Deep yellow to orange--concentrated urine(dehdration) Bilirubin(hepatitis) Foods carrot Drugs..vit c&B Pink to red------haematuria,HB uria Foods..+ Drugs..rifampicine , Metronidazole Brown urine(tea colored)----haematoria of renal Origin Alkaline -----haematuria , uti with proteus, Renal tubular acidosis
[115]

3-PH

Acidic Average 6

4-volume

1,5-3.5ml/kg/h

Oliguria if<1ml/kg/h(400ml/m/day) with concentrated urine eg:dehydration, Glucosuria,prtnuria with renal faiure, diabetes insipedus

5-specific gravity 1010-1020

B-Biochemical Propertertes

Ptotein

Urobilinogen

Traces

Proteinuria--- >150mg/24H Mild..150-500mg/24h Moderate..500-2000mg/day severe>2000mg/day with hepatic jaundice(hepatitis A) Bile pigments normally abscent It appear with hepatic&obstructive Jaundice

Glucose

Nil

[116]

C- MICROSCOPIC PROPERTIES

CELL 1-R.B.C 2-W.BC(pus

cells)

0-5 cell/h.p.f 0-5 cell/h.p.f

Haematuria if > 5 N.B.mild haematuria Occur with Uti with pyuria with vaginal candidiasis c/p:dysuria, ithing,discharge ix: urine analysis--- epith cells ttt:topozol v cream twice/day for one wek Put afilm of cream bt labia majora

3-Epithelial cells

[117]

Crystals A-urate

1-dietary management

-- - 1- : 2-

2-fluid intake 3- drugs: Urosolvin eff sachet 1/2 -1 sachet twice daily Uricol eff sachet 1/2-1 sachet twice daily N.B.....colchicine is contraindicated < 2 years
1- Dietary management 1- 125 : . 2- : ( ) . 3 - 55 4 70 6 80 2

B-oxalate

2-fluid intake 3-drugs Epimag eff sachet Citrocid mg plus eff sachet Dose--------<2 year 1/2 sachet twice daily >2 year 1 sachet twice daily

c-phosphate

acidification of urine by vit c(vitacid c eff tab ) -----,5-1 Gm/day

][118

casts

1-W.B.C cast-----with pyelonephritis

2-granular casts -----also with pyelonephritis

3-Hyaline casts----normal or with nephritic $ 4-Rbc casts----G.N 5-lipoid casts------ nephritic $

Urinary tract infection

Incidence: uti is acommon infection in pediatrics especially females d.t. Short urethra In newborn&young children(<2 years) male to female incidence Is equal

Aetiology: E-COLI responsible for 80-90%of cases

C/p :

Other organismsproteus-klebseilla-pseudomonas GRAM +ve organisms can cause uti blood born infection from Distant septic focus commonly asymptomatic When symptoms appear they are no specific&not related to uriary system

i.e. uti need to be in mind to be diagnosed

lower uti
Mainly local manifestation in infants -low grade fever -crying or discomfort with Urination -foul smelling of urine in older children -dysuria -suprapubic pain -frequency,urgency,hesitancy -incontinence.common -no or low grade fever

Upper uti
Mainly systemic manifestation -high fever -rigor -vomitting -pain in flanks

[119]

Investigations
1-urine analysis: Pus cells--->5 cell/hpf Rbc-----may d.t. congestion 2-C.B.C: leukocytosis 3-Urine culture :when? Scientifically in every case before start of antibiotic therapy But.practically ...if pus cells > 20 or in recurrent uti 4-kidney function tests: in prolonged or recurrent cases

N.B

1- sing&symptoms of uti are present but no pus cells in urine analysis!? Suspect perinephric abscess 2-low pus cell count in urine analysis which donot concides e severe c/p Suspect presence of obstructive uropathy 3-pus cells are present in urine but no growth in culture!? This is sterile pyuria which occur with T.B, Chlamydia,mycoplasm Occur In (precipitating factor): 1-vesicouretric reflux 2-constipationthe dilated rectum compress the bladder And cause voiding dysfunction 3-obstructive uropathy e.g.posterior urethral valve 4-inadequate ttt of attacks of uti 5-urinary caliculi 6-bad toilet hygein especially youg females i.e Back to front washingseeding vagina e microorganisms from stool Investigations: -unine analysis&culture -ultasonography -ascending cystourethrogram -IVP

N.B Recurrent uti

[120]

Treatment: 1-ttt of ppt factors 2-antibiotic according culture & sensitivity test 3-long term prophylaxis by SMX-TMP or nitrofurantoin In small doses for 6 months
Neuropathy so giving vit B complex is

N.B .long term use of nitofurantoin cause peripheral

essential

1-instructions: very important - fluid intake -encourage regular voiding -toilet hygein -----ftont to back i.e. 2-drugs: -analgesic antipyretics-----try to avoid declophenac group(nephrotoxic) -urinary antiseptics-------uricol eff sachets tds -antibiotics : Whar type? empirical antibiotic according to age group till c&s test -Neonates ampicillin 100mg/kg/day + gentamycin 5-7mg/kg/day or amikacin 10-15 mg/kg/d -Infantsceforiaxone 50-75mg/kg/day.of choice Or cefotaxime 100-150mg/kg/day -Children Nitrofurantoin----Dose 6-7mg/kg/day in 2 divided doses Preparations Uvamin retard cap(100mg) Macrofuran cap 50&100 Mepafuran cap 50&100 SMX-TMP---- Dose 1cm/kg/day in 2 divided doses & tab /10kg/day Preparations septrin susp,sutrim susp

Treatment:

If responding continue ttt otherwise shift to results of c&s test

For how long?

For 10-14 day

[121]

N.B
1- you can use 3rd generation parentral for 5 days then shift to oral 3rd gen e.g ximacef or orelox

2--aminoglcosides are more potent than 3rd generation Cephlosporine against grame ve 3- 3rd generation Cephlosporine are more potent than Aminoglcosides against proteus, pseudomonas, Klebseilla 4-ceftazidime is the most potent against pseudomonas 5 -ceftriaxone -----is contraindicated in neonates with Hyperbilirubinaemia 6-smx-tmp------not to be used before 2 months old 7-first generation cephalosporines e.g Cephadroxil(biodroxil-duricef) 50mg/kg/day every 12 h Cephalexin 50-100mg/kg/day They are excreted unchanged in urine so effective in Ttt of uti 8-case of uti not responding to AB therapy suspect Presence of distant septic focus

[122]

Acute post streptococcal glomerulonephritis

Aetiology:
Autoimmune disease following urti or skin infection with group A beta Haemolytic streptococci Skin infection-------common in summer &late autumn Short incubation period URTI----------common in winter and early autumn long incubation period

c/p:

-Haematuriasmoky or cola colored urine -Hypertesionusually do not exceed 200/120 -Oliguriaurine oup put <400ml/m/24h (1-2ml/kg/h) -Oedemamild -Abdominal pain,vomitting -Pallor

I.X:

1-Urine analysis Aspect.turbid Colour.dark or cola colored Volume.decreased Ph..+alkaline RBC casts..diagnostic 2-Evidence of streptococcal infection ASOT.(with cases following URTI) C3 Antihyaluronidase 3-Kindy function test Creatinine.(norml=,3-1mg/dl) BUN.. (normal=10-20mg/d i.e urea2) 4-Serum K(normal= 3,5-5,3 mequ/l)

[123]

Ttt:

1-Eradication of streptococci: Pencillin procaine,oral pencillin or erythromycin for 10 days 2-Oedema: Fluid restriction salt in diet Diureticslasix 1-2 mg/kg/day 3-Hypertension: Mild.lasix 1-2mg/kg/day Moderate to severe.vasodilator e.g: Nifidipine dose----- ,05-,1 mg/kg/day oral or sublinual Preparations----epilat, adalat(10 & 20 mg/cap) Captopril dose-----,5-1,5 mg/kg/day(with caution if creatinine ) Preparation----capoten,capotril tablet 25&50 mg/tab Hydralasine dose----,1-,5 mg/kg/dose iv or im ----,25-1 mg/kg/dose orally Preparations---- apresoline amp 20mg/ml &tablet 25mg 4-TTT of complications: a -Hypertensive heart failure: the problem is volume over load So ttt is diureticslasix 1-2 mg/kg /day b-Hypertensive encephalopathy Clinically:headache Blurring of vision Convulsion Disturbed conscious,semicoma or coma Treatment: nifidedine--,1 mg/kg/dose sublingual Can be repeated after 10 min Up to 3 times (puncture acapsule &instill 5 drop sublingual) Hydralazine--,1-,2mg/kg/dose iv or im Nitroprusside--,5-2mcg/kg/min contiuous iv infusion In icu only Diazoxide---,5-2 mg/kg/dose iv over min Then hift to usual ttt of htn until controlled

[124]

C-Renal failure: usually mild and transient 1-Oliguria N.B . DD of oliguria: Prerrnal.hypovolaemia Renal.intrinsic renal disease(e.g GN) Post renal.obstruction To differentiate bw different causes: 1-catheter test. Urine so its dt postrenal ..no urine so its dt renal or prerenal 2-callenge test to dd bw renal and prerenal Ringers lactate or saline 20cc/kg over 30 min Followed by lasix 2mg/kg iv If no urine.mostly renal If there is urine.mostly prerenal a-Volume expanders: Ringers lactate or saline 20cc/kg over 30 min b-Induction of diuresis: lasix 2mg/kg iv can be repeated in adose 10 mg/kg iv c-Fluid restriction: if upper measures fail to induce adequate diuresis equal to insensible water loss+urine output of previous day (usually 300 ml) Type of fluidglucose:normal saline in aratio of 1:4 No potassium until adequate urine flow is obtained

[125]

2-Hyperkalaemia: Diagnosis: A-serum K: Normal serum K3,5-5,3meq/L Hyperkalaemia> 6meq/L B-ECG: -mild hyperkalaemiaprolonged R,tall peaked T wave -moderate hyperkalaemiaas above+wide QRS comlex -severe hyperkalaemia as above+abscent P -profound hyperkalaemia asystole or ventricular fibrillation TTT : 1-Calcium gluconate. Dose----,5 ml/kg very slowly iv Action----antagonise cardiotoxic effect of K Duration of action----1 hour 2-Sodium bicarbonate Dose----2 meq/kg(4ml of 5%) over 10-15 min Action----intracellular shift of K Duration of action----2 hour 3-Glucose&insulin Dose----,1 unit for every ,5 gm glucose(=2cm of 20%) Action----intracellular shift of K Duration of action----4 hour 4-SalbutamolDose ---,1-,3 ml/10kg neubilizer 5- K chelating agents Dose---- 1gm/kg orally or by high enema Action ---- remove K from body Duration of action----2 hour 6-Dialysis-------- if above measures failed

[126]

Nephritic syndrome
Def & c/p : the characteristic features of N.S. are:
1. Heavy proteinuria > 2 gm/24hours 2. hypoalbuminemia&hpoproteinaemia( normal level of prtn 6-8gm%&albumin 4.55gm%) 3. edema..severe generalized 4. hyperlipidemia ( normal serum 150-250mg%)

Types:
-- Classification of N.S: 1. idiopathic "90% " : a. minimal change nephrotic syndrome 85% b. focal segmental glomerulosclerosis 10% c. mesangial proliferation 5% 2. 2ry to membranous nephropathy, membranous proliferative GN, lupus, Henoch Schonlein purpura, HBV, HCV, HIV 3. Congenital e.g. Finnish syndrome "AR" --Histological types: 1. Minimal change nephrotic syndrome: MCNS "85% bet. Age gps 2-6yrs" 2. focal segmental glomerulosclerosis: FSGS "10%" 3. membranous proliferative glomerulonephritis MPGN "5%"

4.membranous Investigation: Ist line: 1. Urine analysis and pt. protein creatinine ratio 2. CBC 3. RFT: to know if there is some thing affecting the kidney 4. lipid profile : for confirmation of diagnosis 5. serum albumin

[127]

Others; 2nd line: 1. Complements "C3 C4 ": are usually normal b/c. MCNS is the commonest, if they are abnormal "low level" think for other causes and u may consider renal biopsy. 2. ANA: b/c. there are many c/t diseases that affect the kidney, this is for screening for that. 3. ANCA: definitely is not a 1st line is not needed until u have a reason SLE don't give u +ve ANCA SLE gives : +ve Anti dsDNA +ve antiphospholipid Ab +ve ANA ANCA: +ve in case of Wegener and poly arteritis nodosum PAN which is usually rare 4. LFT: generally is not needed, but some time can be valid b/c. there is a certain type of N.S. like MPGN could be related to hepatitis 5. Renal biopsy: is not need as 1st line 6. US. : Really will not tell any thing a part from enlarge, echogenic kidney which is really not specific and not help toward the diagnosis. Treatment of N.S. A-SUPPORTIVE TTT: 1-reasons for admission: -first episode -severe generalized edema(anasarca) while simple edema e.g. puffy face in every morning does need for admission -presence of severe infection,electrolyte disturbanceor hypertension -acute renal failure -Serum albumin <2 g/dl: which result in sever edema, so will not response to simple diuretic .so, we need infusion of albumin so, pt. has to be admitted.
[128]

2-activity: no restriction of activity except e anasarca or R.D 3-Diet: salt restriction & high protein diet 4- Any associated condition u have to care of it e.g. infection treated with antibiotic B-DIFINTIVE TTT: 1-heavy proteiurea without massive edema corticosteroid only: prednisolone2mg/kg/day in single or in two divided doses for 8 weeks 1.5 mg/kg/day single morning doses every other day for 8 weeks 1 mg/kg/day single morning doses every other day for 8 weeks ,5 mg/kg/day single morning doses every other day for 8 weeks 2-heavy proteiurea with moderate edema diureticslasix 2mg/kg/day then corticosteroids 3- heavy proteiurea with massive edema Salt free albumin5ml/kg over 2 hours IV (albumin 20% solution) diureticslasix 2mg/kg/day IV (otherwise volume over load will occur) then shift to oral diuretics &C.S.T 4-frequent relapse Cyclophosphamide 2-3mg/kg/day single dose for 8 weeks Main S/E is bone marrow suppression, lead to neutropenia (quickly develop) + hge cystitis, although thedose is very low in compare to that used forchemotherapy. So, u need to check WBC / wk initially for 3-4wks if its stay well, then u can stop checking or check it every other wk or less freq. U have to use steroid daily or every other day, when he get remission tapering the Dose Indication of renal biopsy: 1. Freq. relapse N.S. 2. no response to treatment 3. Steroid dependant N.S. 4. Steroid resistance N.S. 5. Others e.g. age <2yrsor >10 yrs, associated hypotension or renal dysfunction.

[129]

Nocturnal enuresis
Bedwetting and daytime wetting

It is repeated involuntary voiding at night beyond the expected age for bladder
control Which is usually 5 years Management A-evaluation of condition 1-type 1-primary its continuation of the involuntary control in the earlier years I.e the child has never Attained bladder control It represents 80% of cases +ve family history usually present 2-secondary its the involuntary voiding in previously trained child I.e the child has Attained bladder control for at least 6 months ( ) 2-time 1- nocturnal its night time incontinence(bed wetting) 2- diurnal its both day time & night time incontinence(continuous wetting) 3[130]

Common causes of diurnal enuresis: Pediatric unstable bladder (uninhibited bladder)mot common cause Cystitis Ectopic ureter and fistula Sphincter abnormality (epispadias, exstrophy;urogenital sinus abnormalities) Neurogenic 3-associated clinical manifestations: -in primary typesearch for mental retardation ,sacral anomalies(spinabifida,meningoc Urological anomalies -in secondary typesearch for UTI , polyuria ,emotional stress B-investigations -urine anlysis.. ..to excude UTI & crystaluria ...specific gravity or osmolality, or both, to exclude polyuria as a cause of incontinence and to ascertain that the concentrating ability is normal. ...The absence of glycosuria should be confirmed. -ultrasonography with or without a voiding cystourethrogram...to exclude urological anomalis -urodynamic studes -x ray on sacral spines.. to exclude spina bifida c-treatment - in every case ttt of any organic cause must be done first e.g UTI > 5 years 5-6 years no treatment(till this age the condition is considered physiological)

non pharmacological therapy i.e simple instructions 1-fluid intake should be restricted 3 hours perior to bed time 2-child should void before going to bed 3-child should be awakened 4 hours after he goes to bed to have him void 4-easy access to bathroom and privacy in bathroom 5-motivational counseling: -reassurance of child & parent(explain that the condition is self limited)

[131]

-avoid punitive measures (very important) i.e No blaming or punishment as it aggrevates the condition On contrary praise & reward the child for dry nights 6-bladder training exerciseshelp to stretch bladder &its capacity -bladder stretching by holding urine as long as possible during daytime -increase fluid intake by daytime -stream interruption as much as possible during voiding > 6 years as above +pharmacological therap

Drugs for nocturnal enuresis:

1-anticholinergics Mechanism:spasmolytic action on bladder musculature leading to bladder capacity Dose 5-10 mg/kg/day single dose at bed time Preparationsuripan & detronin tab5mg/tab syrup5mg/5ml Exclusion of UTI must be done first otherwise urinary retention may occur 2-tricyclic antidepressant Mechanism:have acentral &peripheral anticholinergic effect also it may secretion of ADH Dose. - < 6 years: Not established - 6-12 years: 10-25 mg PO hs; if response inadequate after 1 wk of therapy, increase by 25 mg/d PO; not to exceed 2.5 mg/kg/d or 50 mg/dos -> 12 years: Not to exceed 75 mg/dose if no response after 1 month stop drug and shift to other line if favorable response continue on same dose for another 2 months then gradual tapering preparations..tofranil tab 25mg/tab 3-desmopressin Mechanism:synthetic analogue of antidiuretic hormone(ADH) Preparations:minirin .nasal (100 mcg/mL rhinal tube) .PO (0.1- and 0.2-mg tab) Dose :If no response within 2 weeks increase dose to 20mcg/dayPo 0.05-0.2 mg/d Po
at bed time

N.B Bellacid tab belongs to this group e good results

[132]

Dermatology

[133]

Dermatology
A-PTERIASIS ALBA (patchy hypochromia)
Causes
parasitic investation vitamin defeciency Treatment 1-ttt of parasitic investation(see GIT DRUGS) 2-vitamin supplementation Multivitamins - Drops (for younger infants) Preparations enfavit, bebe vit, polyvit drops Dose(for younger infants) < 6months .no need for vit supplementation 6months-1 year. >1 year ...................... - Syrup(for older children) preparationstotavit, vitam, alvital, multisanostol, KG ron,fruital syrup Dose5-10ml/day - chewable tablets Preparationscentrum, chewa-vit, juniors, U.B chewable tab Dose1-2 tab/day

3-topical corticosteroids: Perderm 1% , diprosone, locacorten vioform cream B-INFNTIL ECZEMA

on &off Common in TTT perderm cream twice daily until disappear never to get in contact with eye

C/p redness ,mild swelling on cheeks&chin

[134]

C-URTICARIA Causes ingestant(diet) inhalant(pollens) injectant(drugs) contactant( -) C/pwheel TTT A-antihistamines 1- First generation fenistil drops 1-2drop/kg/day safe from first day of life(cause sedation) others...tavagyl , primaln , phenergan , allergyl ,allergyx syrup 2- second generation a-low sedating citrizine suiphate Preparationcetrak syrup& tab zyretic , histazine 1 syrup &drops can be used from 6 months ongoing Dose.. < 1year 2.5ml/day single dose at night > 1 year 5ml/day single dose at night b-non sedating loratidine can be used after 1 year Preparations------loratan , mosedine , claritine syrup Dose--------------- 1-2 years 2.5 ml/day & > 2 years 5 ml/day desloratidine -desa , deslorat syrup evastine can be used after 2 B- Soothing agents Pan-d , bringo , rash stop , roni derm , no rash , hi derm C-corticosteroids-----in severe cases only Perderm cream twice daily.... never to get in contact with eye
[135]

N.B

Popular urticaria Causeallergic reaction to insect bite C/pon extremities &face(area exposed to insect bites) TTTantihistamines + perderm cream

Napkin dermatitis
it inflammation and erythema of diaper area Types 1-contact napkin dermatitis..d.t prolonged contact with urine and stool or soap No involvement of groin creases 2-monilial napkin dermatitis..d.t supperadded cadidial infection Groin creases are involved TTT
10 ) (

1-mild casespreparations containing zinc oxide e.g Zinc olive lotion,cream o-z cream , three z cream no rash , rash stop cream , camo cream (75 gm) 2-moderate case&severe cases..combined preparations of CST+antifungal e.g Daktacort cream , Nystaform cream Miconaz-H cream , nice-baby cream they are used for 5 days then one of the following preparations is used: miconaz cream daktarin cream , pevaryl cream

[136]

causes of fever with rash

1-varicella(chickenpox) Feverit start with rash. Fever can be mild or high and remain for 2-3 days rashit start in 1st or 2nd day characters of rash centripetal.appear on trunk and fadestowards face&extremities

Very Sick People Must Take Ease

pleomorphic.different types of rash are present at same time e.g vesicles, papules, pustules successive croups pruritic
TTT 1-antihistanime 2-soothing agents 3-antipyretic 4-no AB example:

fenistil drops 1 drop/kg at night pan-d , bringo , rash stop, Hiderm lotion brufen syrup wt/2 every 8 hour

2-scarlet fever
feverit reaches 39-40 c on 2nd day and return to normal over next 5 days(earlier e AB therapy)
rashit appears on 1st or 2nd day soon become generalized, may be associated with vomiting and abdominal pain

it appears as fine paular rash(sand paper or gooseflesh). face appears flushed e circum oral pallor it remains for 3-5 days and fades with branny desquamation characteristic features pharyngitis and strawberry tongue(white then red strawberry tongue) ttt -antibiotic.erythromycin Amoxicillin Amoxicillin clavulinic acid -antipyretic..cetal supp or brufen syrup ( for fear of PSGN) 3- plague..??? 4-measles feverit rises gradually during first 4 days to reach 40c with appearance of rash, then after 2 days it decline to norml
[137]

it is associated with severe cattarhal manifestations(rhinitis,cough,conjuncitivitis) rashit appears in the 4th day first behind ear then become generalized it fades over next 3 days ,it remain for 6 days
characteristic featureskopliks spots(as sand grains opposite the lower molar teeth) TTT -antipyretics.paracetamol or ibuprofen -nasal decongestants &eye dropsnostmine N/E drops 5-typhoid..see typhoid fever micellenous topics 6-erysipelas Roseola infantum(Exanthem sabitum)

N.B

feverit rises rapidly to 39.5-41c and remain for 3-4 days

rashit appear in 4th day with the drop of fever &remain for 24 h

[138]

Other topics

[139]

HEADACHE

[140]

N.B

the main priority is to rule out diagnostic possibilities that may be life-threatening:

Malignant hypertension Increased intracranial pressure (e.g., mass lesion, acute hydrocephalus) Intracranial infections (e.g., meningitis, encephalitis) Subarachnoid hemorrhage Stroke Acute angle closure glaucoma (may appear as a headache, but rare in chiAbnormal neurologic signs

N.B

When should neuroimaging be considered in a child with headache?

Headache increasing in frequency and severity Headache occurring in early morning or awakening child from sleep Headache made worse by straining or by sneezing or coughing (may be a sign of increased ICP) Headache associated with severe vomiting without nausea Headache worsened or helped significantly by a change in position Fall off in linear growth rate Recent school failure or significant behavioral changes New-onset seizures, especially if seizure has a focal onset (see previous discussion) Migraine headache and seizure occurring in the same episode, with vascular symptoms preceding the seizure (20-50% risk of tumor or arteriovenous malformation) Cluster headaches in any child or teenager CLASSIC HEADACHE OF INCREASED INTRACRANIAL PRESSURE Awakens patient from sleep at night Pain present upon awakening in the morning Vomiting without associated nausea Made worse by straining, sneezing, or coughing Intensity of pain changes with changes in body position Pain lessens during the day

N.B

1. 2. 3. 4. 5.

[141]

Typhoid fever(enteric fever)

etiologysalmonella typhi incubation period 1-3 weeks c/p -in young infants - ranges from mild GE to severe fulminant septicemia without diarrhea -Fevere anorexia lethargy weight loss hepatomegally -in older children (it resembles adult typhoid) -begins e high fever,headache,malaise,myalgia,anorexia,vomiting,+ chilly sensation -diarrhea in early stage in <50% of patients,but constipation is noted in later stages -realative bradycardia despite high tempreture -cough is often present -abdominal distension&tenderness -palpation of abdomin: spleen is mildly enlarged,softand tender Doughy sensation+gurgling when cecum is palpated -macular(rose spots)or maculopapular rash may appear on chest&trunk on 5th day of illness -convulsion may occur -by the end of frist week,the child may be very sick with confusion, delirium, and stupor I.X. -CBCrelative leucopenia early in the disease -blood culturepositive during 1st week -stool,urine&bone marrow culturepositive during 2nd&3rd week -widal test

Widal test measures antibodies against O and H antigens of S. Typhi but lacks sensitivity and specificity in endemic areas. Because many false-positive and false-negative results occur, diagnosis of typhoid fever by Widal test alone is prone to error -usually positive during 2nd&3rd week -high titer of 0 ( 4 folds normal ie 1/360) suggest the presence of active infection
-high titer of H suggest past infection or past immunization False negative early in the disease(during 1st week) Early ttt with proper antibiotics(may suppress antibody formation) False positive previous TAB vaccination(high 0 +high H) Anamnestic reaction(non specific agglutination e other non slamonellal antibodies)
[142]

TTT -general supportive: Antipyretics Soft diet&liquids Adequate fluid&electrolyte balance -antibiotics: -Oral Fluoroquinolones ? only > 18 year old oral 3rd generation cephalosporine (the best oral therapy)

-oral 3rd generation

1-cefixime
8 mg/kg/day single dose or in 2 divided doses Ximacef &suprax Susp 100mg/5ml cap 200mg/cap Not antistaph Not antipseudomonal

2-cefpodoxime

Used mainly in ttt of 1o mg/kg/day in 2 divided Orelox susp 40mg/5ml Uti , typhoid fever,OM Tab 100mg & sinusitis doses

amoxicillin chloramphincol SMX-TMP Azithromycin

100g/kg/day in 4 divided doses(high relapse rate) 50-100 mg/kg/day oral or iv 1cm/kg/day in 2 doses 10g/kg on day 1, followed by 5 mg/kg for 7 days

-Parentral.. 3rd generation cephalosporine Cefotaxime 100-150mg/kg/day in divided doses Ceftriaxone 50-75 mg/kg/day single daily dose Ceftazidime 100-150 mg/kg/day in 2 divided doses

[143]

OPTIMAL THERAPY SUSCEPTIBILITY Fully sensitive Antibiotic Daily Dose (mg/kg/day)

ALTERNATIVE EFFECTIVE DRUGS Days Antibiotic 14 21 14 57 714 7 10 14 14 Fluoroquinolone, 15 e.g., ofloxacin or ciprofloxacin 10 14 Azithromycin Cefixime Cefixime 810 1520 20 7 7 14 7 14 Daily Dose (mg/kg/day) Days 57

UNCOMPLICATED TYPHOID FEVER Chloramphenicol 5075 Fluoroquinolone, 15 e.g., ofloxacin or ciprofloxacin

Amoxicillin Multidrug resistant

75100

Fluoroquinolone 15 or cefixime 1520

Quinolone resistant[] Azithromycin or 810 ceftriaxone 75 SEVERE TYPHOID FEVER Fully sensitive Ampicillin or ceftriaxone 100

6075 Multidrug resistant Fluoroquinolone 15

10 14 10 14 10 14 Ceftriaxone or cefotaxime 60 80 10 14 14

Quinolone resistant

Ceftriaxone

6075

Fluoroquinolone 2030

[144]

Ricket It is rickets? s 1-skeletal mainfestationsmost important diagnostic feature

-head...large head, frontal bossing, delayed closure of fontanel, delayed teething -thorax.rosary beads(enlarged costocondral junction) Harisson sulcus(longitudinal groove at lower costal margin) Longitudinal sulcus(vertical groove behind rosary beads) + chest deformity -limbs..broad epiphysis at lower end of ulna&radius Marfan sign(transverse groove palpated over the medial malleoli) + limb deformity -spine.correctable kyphosi 2-muscular mainfestations: -delayed motor development(delayed sitting , crawling , standing , walking) -abdominal distension -viscerotois(palpable liver &spleen) 3-neurological Mainfestation: -anorexia ,irritability , sweating -tetany

what is the cause?

Causes of rickets: a-nutritional most common(vit D rickets) due to..defective intake or synthesis of VIT D e.g:
-prolonged breast feeding or fresh cow milk with out VIT D supplementation e food rich in VIT D

-lack of exposure to sun rays

Clinically.usually between 6 months-2years &dietitic error is ujually evident Laboratory. Normal serum Calcium , low phosphate , high alkaline phosphatase Threapeutically there is good response to ujual dose of VIT D . such response can be denomestrated radiologically after 2-3 weeks of intiation of therapy

[145]

b- non nutritional rickets(VIT D resistant) due todefective absorption (malabsorption $ ,celiac disease ,steatorrhea) defective activation (renal rickets &hepatic rickets) clinically.usually after 2years OR before 6 months theraputicallydo not respond to usual dose of VIT D conclusion radiological signs of healing in nutriyional rickets start after 2 weeks of onset of VIT D therapy(healing rickets)&become completed after 4weeks(healed rickets) failure to respond to VIT D after 4 weeks should suggest VIT D resistant rickets and some investigations are necessary to identify the causitive disease I.X. 1-serum Calcium , phosphate , alkaline phosphatase 2-acid base balance (to detect metabolic acidosis) 3-evaluation of renal function 1-radiological plain X ray on wrist (better on knee Bone growth is most rapid in this area, and rachitic changes are seen earliest at this location.) will show signs of activity:

Its active or not?

Cupping, fraying, and irregularity of the metaphyses Widening of the physis as a result of increased osteoid Loss or increased separation of the zone of provisional calcification Periosteal reaction (appears to separate from diaphysis as a result of increased osteoid) Coarsening of trabeculae Loss of bone density Bowing of long bone

[146]

2-clinically

Presence of skeletal mainfestation do not mean that it is active rickets, but presence of Hypotonia (muscular mainfestatoin) or tetany(neurological mainfestation) are signs Of activity 1-history of motor development delayed motor development indicate activity 2-history of VIT D intakeabsent intake favour activity 3-presence of latent tetany 1-correction of dietitc error..diet rich in VIT D e.g -- - 2-exposure to ultraviolet sunrays 9-8 5-4 3-drugs a-VIT D Doseprophlyaxsis 400 iu/day Treatment 2000-3000 iu day Preparationsdrops vidrops 100 iu/drop syrupdecal B12 , calci-cal , vitacal (each 5ml=1000IU VITD+50mg Ca +10 mcg VIT B12)
b-Calcium(only in severe cases not in mild to moderate cases) Dose40mg elemental Ca/kg/day Peparation..Hical (78 mg elemental Ca/5ml) Cal-D-B12 OR CAlcid B12(50mg elemental Ca /5ml) Calcium Sandoz (110 mg elemental Ca /5ml)
N.B

What is the Treatment ?

Roughly vidrops 10 drop tds Hical 5ml/day or every other day

[147]

Neonatology

[148]

Neonatal Examination

[149]

Neonatology resuscitation
See text

N.B
oxygen therapy:
Indications 1-during neonatal resuscitation 2-any patient with respiratory distress is in need to oyggen 3-cyanosis(cardiac or respiratory) with RD is an urgent indication of 02 4-hypoxia with pa02 <50 torr 5-neonatal apnea 6-acute severe brain insult,coma,and seizures Method of giving 02:

1-enriching the incubator atmosphere 2-oxygen hood(head box ,oxyhood) 3-the ordinary face mask 4-nasal cannula 5-nasal prongs 6-nasopharyngeal mask 7-endotracheal tube

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Respiratory distress

See text

-Respiratory problems are the commonest cause of serious neonatal illnee&death -Respiratory distressusually presents as acombination of grunting,tachypnea,nasal flaring,Sternal&intercostal retraction+cyanosis Causes of respiratory distress A-Respiratory causes: -Respiratory distress $(RDS) -Muconium aspiration $ -Transiet tachypnea of newborn(TTN) -Neonatal pneumonia -Air leak(pneumothorax) -Chronic lung disease(bronchopulmonary dysplasia) -Airway obstruction(bilateral choanal atresia) B-Cardiac causes: -Heart failure(HF) -Persistant fetal circulation(PFC) -Persistant pulmonary hypertension(PPHT) -PDA C-Central causes: -Hypoxic ischaemic encephalopathy -Intracranial haemorrhage -Meningitis D-Haematological -Severe anaemia or polycythemia E-Other -Sepsis ,metabolic acidosis ,overheating ,hypoglycemia DD of RD See text

1-Respiratory distress $ Etiologysurfactant deficiency Those at risk are: 1-prematurity(immaturity of the lung) 2-maternal diabetes 3-cessarain section delivery 4-multiple pregnancy 5-perinatal asphyxia
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Diagnosissee text

Tranient tachypnea of the newborn(TTN)

ETtology delayed clearance of fetal lung fluid(hence the name wet lung disease) those at risk are: 1-Delivery by elective CS 2-Maternal sedation 3-Delayed clamping of cord 4-Premature delivery Diagnosis Onsetrespiratory distress appear within few hours after birth(1-3h) Distressusually mild(tachypnea100 br/min or less ,mild grunting ,few retracrions) CXRhyperexpantion of the lung(hallmark of TTN) Prominent peri-hilar streaking Fluid in minor fissure Prominent pulmonary vascular markings Magenent 1-correction of hypoxia02 byhead box .CPAP may be needed in some infants 2-chest physiotherapyHow?Tapping on chest(front, back ,sides)by mask of ambou 3-antibiotics.ampicillin+aminoglycosides I far to start with
4-fluid,electrolytes&feeding

-start with IVF then shift to oral feeding according to improvement of respiration -start IVF with 60ml/kg dextrose 10% in first day -in second day :give 70ml/kg(NS 13ml/kg/d+Ca 2-5ml/kg/d+restis dextrose 10%) -start feeding when the RR is < 90 br/min by NG tube &when reach~60 br/min Oral feeding is intiated

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Meconium aspiration $
Etiology&pathophysiology -Meconium is the first stool of the newborn passes after
birth.its greenish black viacid stuff Formed by biles,intestinal secretions & epithelial debrith present in the fetal gut acute or chronic fetal hypoxia stimulates fetal peristalsis and relaxes the anal sphincter leading To passage of meconium in the aminiotic fluid.also,this hypoxia leads to stimulation of fetalRespiration and hence aspiration of the meconium containing aminiotic fluid

The aspirated mecomium leads to:

-chemical irritation and inflammation of the lung(chemical pneumonitis) -promotion of bacterial growth(pneumonia) -airway obstruction either: Partial obstruction(ball valve) air trappingover inflation&emphysema;with the possibility Of air leak(pneumothorax) Complete obstructionatelectasis

Those at risk are:

Term and post term infants who suffer from placental insufficiency Diagnosis -Greenish discoloration of the aminiotic fluid,skin,nail&umbilical cord are very pthognomonic -RD usually appears quickly after birth and may be severe -air trappin cause lung overdistention,anterior bowing On auscultation there are widespread added sounds with rhonchi and fine or sticky crepititions

CXR
-lung looks over-expanded and contain multiple areas of atelactasis -air leak(pneumothorax,pneumomediastinum) management -try to be prepared for the condition (this needs good cooperation between the obstetrician&Neonatologist who should attend the delivery with all the resuscitation equipment) -suction of the mouth then nose before delivery of the shoulder then the baby is wrapped by Preheated towel to prevent intiation of respiration and placed on the preheated Warmer -tracheal lavagethrough an endotracheal tube put-1ml saline the do suction repeat again And again till fluid comes clear
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(donot ventilate before this otherwise you will push Meconium particles more distally) -02 & ventilator support -early surfactant therapy may benefit the infant -antibiotics all infants should receive broad spectrum AB -intravenous fluids &nutrition before entral feedins pneumothorax -ttt of comx e.g -diagnosis -clinically -sudden onset of cyanosis -increase in respiratory effort or rate -shift of heart beat -breath sounds arelouder over one lung -deterioration of general condition, mottling of skin and sluggish peripheral blood flow -development of low blood pressure -episodes of apnea and bradycardia
-Radiologically

AP and lateral view;the jet-black appearance, shift of mediastinum,

-TTT
-butterfly cannula in 2nd intercostals space mid clavicular line connected to under water seal -OR chest tube Size.8-10 Site.4th space anterior axillary line at upper border of rib below

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Neonatal jaundice

See text

definitionyellow discoloration of skin,sclera,&mucos membranes due to increased level bilirubin in blood,jaundice is clinically observed in the newborn infant when the total serum bilirubin reaches 5-7 mg/dl (>2mg/dl in older children) .it first appear in face then descend downward as the level increase source of bilirubin causes of neonatal jaundice a-unconjugated hyperbilirubinemia b-conugated hyperbilirubinemia A-uncongated hyper bilirubinemia..1-production 2-uptake&conjugation 1-production : -hemolytic anemias(RH &ABO incompatibility ,G6PD deficiency, hereditary spherocytosis) -polycythemia -excess bruises and hematomas(cephalohematoma, subaponeuritic haemorrhage) 2-uptake &conjugation -physiological jaundice of newborn -immature liver(especially In the preterm) -competitive inhibition:breast milk jaundice -deficient uptake(Gilbert disease) -hereditary(Crigler-Najjer $)

b-conjugated hyperbilirubinemia:
1-hepatocellular: hepatitisA-E,rubella,herpes simplex,toxoplasmosis bacterial sepsis inborn error of metabolism 2-cholestatic: Biliary atresia Bile duct stenosis Bile mucos plug ,choledocal cyst
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Physiological jaundice
This is the most common cause of jaundice in newborn.it occur in about 60% of full term Newborn infants and more in premature

Causes:

1-bilirubin load on liver: -short live span of fetal RBC -high RBC mass in newborn -enterhepatic circulation of bilirubin(Bglucuronidase enzyme present&putrefactive flora absent) 2-uptake of bilirubin By the liver(transient immaturity of Z&Y protein) 3-conjugation of bilirubin by liver(transient immaturity of glucoronyl transferase enzym ) Above mentioned causesare also applicable in preterm newborn but they are more exaggerated Plus: -open ductus venosus shunts the blood from the portal vein to the inferior vena cavathus Bypassing the liver -hypoglcemiaUDPGneeded for conjugation

Manifestations:
1-aundice usually appears in 2nd or 3rd day(not in first 24 h) 2-the rise in bilirubin is less than ,5 mg/dl/h 3-the peak level of serum bilirubin is less than (12 mg/dl in full term &15mg/dl in preterm) 4-jaundice usually donot persist after 5-7 days 5-the jaundice is of unconjugated type 6-the newborn is healthy, feeds well Level under 2mg/dl may not be reached till age of one month 7-no anaemia(normal hemtocrit level) 8-urine and stool are normal The physiological jaundice may be prolonged in -hypothyrodismthyroxin is neededfor maturation of enzyms&GIT motility -breast milk jaundice in some exclusively breast fed babies -pyloric stenosis-delayed passage of stool
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Treatment see text

N.B
What to do first

Careful history & physical exam to exclude life-threatening

problems like sepsis, to identify infants w/ hemolytic disease

General measures: Phototherapy

_ First-line treatment _ Generally begun 45 mg/dL below exchange transfusion level (see below) Clinical pearls _ Maximize skin surface area exposed to phototherapy (if bilirubin levels high, use fiberoptic pad underneath infant and lights from above) _ Special blue/tungsten lights most effective (caution: tungsten halide lamps produce a lot of heat, can burn skin if placed too close) _ Light does not have to be administered continuously; lights can be turned off briefly (for intervals of 1530 min) w/o losing effectiveness _ If meter available to measure energy output of phototherapy light, use doses of light >= 10 micro watts/cm2/nm _ Dose-response relationship between energy output of light, decrement in serumbilirubin _ Doses of light up to 30 micro watts/cm2/nm increasingly effective _ Risks _ Increased insensible H2O loss (minor issue) _ Increased stooling (rare) _ Bronze baby syndrome (rare) _ Overheating/burning (preventable)

Exchange transfusion (EXTX)

_ Used when serum bilirubin concentration reaches level that places infant at risk for bilirubin-induced brain injury General guidelines for phototherapy & exchange transfusion Preterminfants _ Birth wt <1250 g: photorx @ total serum bilirubin (TSB) 57,
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EXTX @ TSB 1013 _ Birth wt 12501499 g: photorx @ TSB 710, EXTX @ TSB 1316 _ Birthwt 15001999 g: photorx@TSB 1012, EXTX@TSB 1618 _ Birthwt 20002500 g: photorx@TSB 1214, EXTX@TSB 1820 note: Preterm infants w/ risk factors for kernicterus should be exchanged at lower part of range; risk factors incl perinatal asphyxia, ongoing hypoxemia, persistent hypothermia, hypoalbuminemia (<2.5 g/dL), hemolysis, sepsis or CNS depression Healthy termnewborns _ Age <24 h: term infants who become jaundiced in first 24 H of life not considered healthy _ Age 2548 h: photorx @ TSB >15, EXTX @ TSB >20, if photorx fails, EXTX + photorx @ TSB >25 _ Age 4972 h: photorx @ TSB >18, EXTX @ TSB >25, if photorx fails, EXTX + photorx @ TSB >30 _ Age >72 h: photorx @ TSB >20, EXTX @ TSB >25, if photorx fails, EXTX + photorx @ TSB >30 Sick term newborns or term newborns w/ suspected/proven hemolysis _ Age <24 h: photorx @ TSB >1014, EXTX @ TSB >20 _ Age >= 24 h: photorx @ TSB >15, EXTX @ TSB >20

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Neonatal infection
Infections are afrequent cause of neonatal morbidty&mortality what gives them special importance? -their presentation is usually vague and may resemble many ther common dieases -the routine laboratory tests are of no great help in their diagnosis -the host resistance mechanisms of neoborn are easily over comed by micro-organisms Classification; A-Minor infection.-infection of skin e.g napkin dermatitis -infection of breast tissue -infection of conjunctiva(ophthalmia neonatorum -trush stomatitis -umbilical infection B-major infections 1-congenital infections 2-neonatal sepsis syndrome

Neonatal sepsis
Definition..neonatal sepsis is a clinical(&laboratory)$ caused by the metabolic and hemodynamic Consequences of infection during the 1st month of life In most cases the condition is not localized and called neonatal septicemia in other cases,in addition to its systemic nature of the infection could be localized to give for example:pneumonia,meningitis,septic arthritis,uti the most common organisms: -E-coli -group B strepto -Enterococcus -proteus&pseudomonas -listeria monocytosis -klebsiella The predisposing factors: One can distinguish two patterns of neonatal sepsis: 1-early onset. start usually in the first week related to obstetric risks, mainly caused by organisms present in the cervix&vaginal canal 2-late onset.. start usually after the first week, not related to obstetric risks, mainly caused by more virulent organisms as staph ,pseudomonas
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1-maternal.premature rupture of membranes,traumatic or prolonged delivery,maternal uti 2-neonatal.prematurity,endotracheal intubation,umbilical catheterization,mechanical Ventilation

Diagnosis
History of risk facors Early manifestations
usually vague and non specific the baby is not doing well or sick(poor suckling,lethargy,vomiting,fever or hypothemia)

Late manifestation..

usually related to different systems serious focal infections e.g meningitis,pneumonia,uti,NEC,septicarthritis,DICetc

Laboratory

triple tap { blood+CSF+urine } for laboratory work

laboratory evidence of infection -cultures : blood,CSF,urine -antigen detection: CSF,urine laboratory evidence of inflammation -total white cell count below 5000/mm or above 30000/mm -CRP above 20mg/liter -band cell above 10% -ESR above 15 mm/first hour Laboratory evidence of multi-system organ disease -metabolic acidosis(pco2,pH) -renal function(BUN,creat) -liver function(SGOT,SGPT) -bone marrow(anemia,neutropenia) Treatment. 1-Specific ttt a-Antibiotics start immediately,modify after the results of culture&sensitivity test Srart with ampicillin +gentamycin or amikin or tobramycin or cefotaxime Duration 2weeks minimally ,3weeks with meningitis, 4weeks with septic arthritis b-Gammaglobulin.,2gm/kg iv for 2-Supportive tttmaintain good fluid&electrolyte balance Ventilator support Blood transfusion or even exchange transfusion single volume transfusion (wt x 80)

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